People to Meet at KataCon

KataCon is a couple of weeks out. If you are considering going you are probably looking at the keynote speakers and KataGeekYellowbreakout workshops.

The other reason to attend KataCon is to meet other people and share experiences with them. I’d like to introduce you to two of those people.

imageHal Frohreich is the Chief Operating Officer of Cascade DAFO in Ferndale, Washington. Their product is custom pediatric foot / ankle orthotics that help kids walk. Yup, custom. Every one is different.

Since taking the position, Hal has been using Toyota Kata as a mechanism to develop the leadership and technical skills of the supervisors and, in doing so, make fundamental shifts to the culture of the organization. For you TWI folks, he has also deployed TWI, especially Job Instruction, along side the Toyota Kata for much more consistency in the way work is performed.

 

 

imageHal provides support to his Production Manager, Tim Grigsby. Tim coaches 4-7 kata boards every day and covers diverse areas including people development, I.T. issues, R&D, and production. Tim views his job as seeing that each work team has the time, education, direction, space, tools and help to improve their work. Toyota Kata provides the structure that he uses to help them develop critical thinking and clarity in their target conditions, obstacles, and their PDCA cycles.

Each afternoon the COO and CEO walk the floor and review the target conditions, obstacles and next steps. This helps keep things aligned as well as ensure nobody is “stuck” on a problem that is outside of their scope to fix.

 

I believe, and teach, that Toyota Kata is a mechanism for driving culture change, and this is the philosophy that Hal and Tim have embraced. While the performance of the organization has dramatically improved by every measure you care to ask about, that is not the real result of this work.

The real outcome has been to create a cadre of front-line leaders that are taking initiative and applying creative solutions vs. just getting through the day doing what they are told.

Come to KataCon and find these guys. They are worth talking to.

Learning = Extending the Threshold of Knowledge

“My computer won’t boot.”

Mrs. TheLeanThinker’s computer was hanging on the logo screen, keyboard unresponsive.

I know already that if the CPU were bad it wouldn’t get this far.

I also knew that the system hasn’t even tried to boot the OS from the hard drive yet, so that likely isn’t the problem.

Working hypothesis: It’s something on the motherboard.

Start with the simple stuff that challenges the working hypothesis:

  • Hang test a different, known good, power supply. No change.
  • Pull memory cards and reinstall them one by one. No change.
  • Pull the motherboard battery, unplug, wait a few minutes to possibly reset the BIOS. No change.
  • Try holding down the DEL key on power-up to get into BIOS settings. Nope, system still hangs, though it does read that one keystroke, the keyboard is dead after that.
  • Try Ctrl-Home to reach the BIOS flash process. Nope.

image

There is no evidence that the motherboard is not dead. Final test:

Get the numbers off the motherboard, find the same model on Amazon, order it for $37.50 to the door. (Intel hasn’t made this processor type since 2011).

New motherboard arrived today. Switch it out, takes about 30 minutes.

Boot up the machine, works OK, set the time in the BIOS, and pretty much good to go.

Convince Windows 10 that I haven’t made a bootleg copy.

Done.

The Threshold of Knowledge

I learned to code in 1973 on PDP-8 driving teletypes. Although my programming skills are largely obsolete these days, I am comfortable poking around inside the box of a PC, and I generally know how they work. Thus, the troubleshooting and component replacement I described above was not a learning experience. Yes, I learned what was wrong with this computer. (The “bad motherboard” was a hypothesis I tested by installing a new one.) But I didn’t learn anything about computers in general.

Rather than working through experiments into new territory, I was troubleshooting. Something that had worked was not working now. My experiments were an effort to confirm the point of failure.

Therefore, as interesting as the diversion was, aside from a little research on some of the more arcane troubleshooting, it was not a learning exercise for me. It was all within my Threshold of Knowledge.

In the Improvement Kata, “threshold of knowledge” refers to the boundary between “We know for sure” and “We don’t know.” Strictly speaking, we only say “We know” when there is specific and relevant evidence to back it up.

image

In this case, my challenge (fix the wife’s computer) was well inside the red circle.

But this wouldn’t be the case for everyone.

The Threshold of Knowledge is Subjective

Someone else with the same challenge may not see this as a routine troubleshoot-and-repair task. Rather, he has to learn.

I had to learn it at some point as well. The difference is that I had already learned it. I had already made mistakes, taken a week to build a PC and get it working many years ago. I learned by experimenting and being surprised when something didn’t work, then digging in and understanding why. On occasion, especially in the early days, I consulted experts who coached me, or at least taught me what to do and why.

Coaching To Extend the Threshold of Knowledge

Learning is the whole point of the Improvement Kata. That is why we call the “improver” the “learner.” If someone encounters a problem like my example and I am responsible for developing their skills, I am not serving them if I do something like:

  • Sit down at their machine and troubleshoot it.
  • Tell them what step to take, and asking what happened so I can interpret the outcome.

That second case is deceptive. The question is “Who is doing the thinking?” If the coach is doing the thinking, then the coach isn’t coaching, and the learner isn’t learning.

In this case I would also have to recognize this is going to take longer than it would if I did it myself. That is a trap many leaders fall into. They got where they are because they can arrive at a solution quickly. But the only reason they can do that is because, at some point in the past, they had time to learn.

“My computer doesn’t boot.” If my objective is for this person to learn, then I need to go back to the steps of learning. Given that the challenge is likely “My computer operates normally,” what would be my next question to help this person learn how to troubleshoot a problem like this?

I need to know what they know. “Do you know where in the boot sequence it is hanging up?” If the answer is “No,” or just a repeat of the symptom, then my next target condition is for them to understand the high-level sequence of steps that happens between “ON” and the login screen. That would be easy to depict in a block diagram. It’s just another process. But my learner might have to do a little research, and I can certainly point him in the right direction.

I’m not going to get into the details here, because this post isn’t about troubleshooting cranky computers.

General Application

“If somebody comes to me with a problem, I have two problems.”

  • The original issue.
  • The fact that this person didn’t know how to handle it.

You can easily translate my computer example into a production quality example. A defect is produced by a process that normally does not produce them. What is different between “Defect” and “Defect-Free?” Something is. We just don’t know what.

Is it something we need to learn? Something we need to teach? Or something we need to communicate?

If my working challenge for my organization is something like “Everyone knows everything they need to do their jobs perfectly.” then I am confronted every day with evidence that this is not as true as I would like.

If I look at those interventions as “the boss just doing his job” then I lose the opportunity to teach and to grow the organization. I am showing how much I know, and by doing so just extending the dependency. That might feel good in the short term, but it doesn’t do much for the future.

Think about this… in your organization, if the boss were promoted or hired out of the job tomorrow, would you look outside the immediate organization for a replacement? If so, you are not developing your people. When I see senior leaders being hired from outside, all I can do is wonder why they have so little faith in the people they already have.

_________

*I remember when Gateway built their own machines, which I guess shows how long I’ve been playing with PCs. Then again, I remember when the premium brand was Northgate. Of course, I also remember programming on punch cards.

Toyota Kata: Reflection on Coaching Struggling Learners

The “Five Questions” are a very effective way to structure a coaching / learning conversation when all parties are more or less comfortable with the process.

The 5 Questions of the Coaching Kata

Some learners, however, seriously struggle with both the thinking pattern and the process of improvement itself. They can get so focused on answering the 5 questions “correctly” that they lose sight of the objective – to learn.

A coach, in turn, can exacerbate this by focusing too much on the kata and too little on the question: “Is the learner learning?”

I have been on a fairly steep learning curve* in my own journey to discover how modify my style in a way that is effective. I would like to share some of my experience with you.

I think there are a few different factors that could be in play for a learner that is struggling. For sure, they can overlap, but still it has helped me recently to become more mindful and step back and understand what factors I am dealing with vs. just boring in.

None of this has anything to do with the learner as a person. Everyone brings the developed the habits and responses they have developed throughout their life which were necessary for them to survive in their work environment and their lives up to this point.

Sometimes the improvement kata runs totally against the grain of some of these previous experiences. In these cases, the learner is going to struggle because, bluntly, her or his brain is sounding very LOUD warning signals of danger from a very low level. It just feels wrong, and they probably can’t articulate.

Sometimes the idea of a testable outcome runs against a “I can’t reveal what I don’t know” mindset. In the US at least, we start teaching that mindset in elementary school.

What is the Point of Coaching?

Start with why” is advice for me, you, the coach.

“What is the purpose of this conversation?” Losing track of the purpose is the first step into the abyss of a failed coaching cycle.

Coach falling over a cliff.

Overall Direction

The learner is here to learn two things:

  • The mindset of improvement and systematic problem solving.
  • Gain a detailed, thorough understanding of the dynamics of the process being addressed.

I want to dive into this a bit, because “ensure the learner precisely follows the Improvement Kata” is not the purpose.

Let me say that again: The learner is not here to “learn the Improvement Kata.”

The learner is here to learn the mindset and thinking pattern that drives solid problem solving, and by applying that mindset, develop deep learning about the process being addressed.

There are some side-benefits as the learner develops good systems thinking.

Learning and following the Improvement Kata is ONE structured approach for learning this mindset.

The Coaching Kata, especially the “Five Questions” is ONE approach for teaching this mindset.

The Current Condition

Obviously there isn’t a single current condition that applies to all learners. But maybe that insight only follows being clear about the objective.

What we can’t do is assume:

  • Any given learner will pick this up at the same pace.
  • Any given learner will be comfortable with digging into their process.
  • Any given learner will be comfortable sharing what they have discovered, especially if it is “less than ideal.”

In addition:

  • Many learners are totally unused to writing down precisely what they are thinking. They may, indeed, have a lot of problems doing this.
  • Many learners are not used to describing things in detail.
  • Many learners are not used to thinking in terms of logical cause-effect.
  • The idea of actually predicting the result in a tangible / measurable way can be very scary, especially if there is a history of being “made wrong” for being wrong.

Key Point: It doesn’t matter whether you (or me), the coach, has the most noble of intentions. If the learner is uncomfortable with the idea of “being wrong” this is going to be a lot harder.

Summary: The Improvement Kata is a proven, effective mechanism for helping a learner gain these understandings, but it isn’t the only way.

The Coaching Kata is a proven, effective mechanism for helping a coach learn the skills to guide a learner through learning these things.

For the Improvement Kata / Coaching Kata to work effectively, the learner must also learn how to apply the precise structure that is built into them. For a few people learning that can be more difficult than the process improvement itself.

Sometimes We Have To Choose

A quote from a class I took a long time ago is appropriate here:

“Sometimes you have to choose between ‘being right’ or ‘getting what you want.’”

I can “be right” about insisting that the 5 Questions are being answered correctly and precisely.

Sometimes, though, that will prevent my learner from learning.

Countermeasure

When I first read Toyota Kata, my overall impression was “Cool! This codifies what I’ve been doing, but had a hard time explaining.” … meaning I was a decent coach, but couldn’t explain how I thought, or why I said what I did. It was just a conversation.

What the Coaching Kata did was give me a more formal structure for doing the same thing.

But I have also found that sometimes it doesn’t work to insist on following that formal structure. I have been guilty of losing sight of my objective, and pushing on “correctly following the Improvement Kata” rather than ensuring my learner was learning.

Recently I was set up in the situation again. I was asked to coach a learner who has had a hard time with the structure. Rather than trying to double down on the structure, I experimented and took a different approach. I let go of the structure, and reverted to my previous, more conversational, style.

The difference, though, is that now I am holding a mental checklist in my mind. While I am not asking the “Five Question” explicitly, I am still making sure I have answers to all of them before I am done. I am just not concerned about the way I get the answers.

“What are you working on?” While I am asking “What is your target condition?,” that question has locked up this learner in the past. What I got in reply was mostly a mix of the problems (obstacles) that had been encountered, where things are now, (the current condition), some things that had been tried (the last step), what happened, etc.

The response didn’t exactly give a “Target Condition” but it did give me a decent insight into the learner’s thinking which is the whole point! (don’t forget that)

I asked for some clarifications, and helped him focus his attention back onto the one thing he was trying to work out (his actual target condition), and encouraged him to write it down so he didn’t get distracted with the bigger picture.

Then we went back into what he was working on right now. It turned out that, yes, he was working to solve a specific issue that was in the way of making things work the way he wanted to. There were other problems that came up as well.

We agreed that he needed to keep those other things form hurting output, but he didn’t need to fix them right now. (Which *one* obstacle are you addressing now?). Then I turned my attention back to what he was trying right now, and worked through what he expected to happen as an outcome, and why, and when he would like me to come by so he could show me how it went.

This was an experiment. By removing the pressure of “doing the kata right” my intent is to let the learner focus on learning about his process. I believe I will get the same outcome, with the learner learning at his own pace.

If that works, then we will work, step by step, to improve the documentation process as he becomes comfortable with it.

Weakness to this Approach

By departing from the Coaching Kata, I am reverting to the way I was originally taught, and the way I learned to do this. It is a lot less structured, and for some, more difficult to learn. Some practitioners get stuck on correct application of the lean tools, and don’t transition to coaching at all. I know I was there for a long time (probably through 2002 or so), and found it frustrating. It was during my time as a Lean Director at Kodak that my style fundamentally shifted from “tools” to “coaching leaders.” (To say that my subsequent transition back into a “tools driven” environment was difficult is an understatement.)

Today, as an outsider being brought into these organizations, my job is to help them establish a level of coaching that is working well enough that they can practice and learn through self-reflection.

We ran into a learner who had a hard time adapting to the highly structured approach of the Improvement Kata / Coaching Kata, so we had to adapt. This required a somewhat more flexible and sophisticated approach to the coaching which, in turn, requires a more experienced coach who can keep “the board” in his head for a while.

Now my challenge is to work with the internal coaches to get them to the next level.

What I Learned

Maybe I should put this at the top.

  • If a learner is struggling with the structured approach, sometimes continuing to emphasize the structure doesn’t work.
  • The level of coaching required in these cases cannot be applied in a few minutes. It takes patience and a fair amount of 1:1 conversation.
  • If the learner is afraid of “getting it wrong,” no learning is going to happen, period.
  • Sometimes I have to have my face slammed into things to see them. (See below.)
  • Learning never stops. The minute you think you’re an expert, you aren’t.

__________________

image* “Steep learning curve” in this case means “sometimes learning the hard way” which, in turn means, “I’ve really screwed it up a couple of times.”

They say “experience” is something you gain right after you needed it.

Coaching Kata: Walking Through an Improvement Board

Improver's Storyboard

The Coaching Kata is much more than just asking the 5 questions. The coach needs to pay attention to the answers and make sure the thinking flows.

Although I have alluded to pieces in prior posts, today I want to go over how I try to connect the dots during a coaching cycle.

Does the learner understand the challenge she is striving for?

The “5 Questions” of the Coaching Kata do not explicitly ask about the challenge the learner is striving for. This makes sense because the challenge generally doesn’t change over the course of a week or two.

But I often see challenges that are vague, defined only by a general direction like “reduce.” The question I ask at that point is “How will you know when you have achieved the challenge?

If there isn’t a measurable outcome (and sometimes there isn’t), I am probing to see if the learner really understands what he must achieve to meet the challenge.

This usually comes up when I am 2nd coaching and the learner and regular coach haven’t really reached a meeting of the minds on what the challenge is.

Is the target condition a logical step in the direction of the challenge?

And is the target condition based on a thorough grasp of the current condition?

I’m going to start with this secondary question since I run into this issue more often, especially in organizations with novice coaches. (And, by definition, that is most of the organizations where I spend time.)

It is quite common for the learner to first try to establish a target condition, and then grasp the current condition. Not surprisingly, they struggle with that approach. It sometimes helps to have the four steps of the Improvement Kata up near the board, and even go as far as to have a “You are here” arrow.

Four steps of the Improvement Kata
(c) Mike Rother

Another question I ask myself is Can I directly compare the target condition and the current condition? Can I see the gap, can I see the same indicators and measurements used for each so I can compare “apples vs apples”?

Along with this is the same question I ask for the challenge, only more so for the target condition:

How will the learner be able to tell when the target is met? Since this has a short-term deadline, I am really looking for a crisp, black-and-white line here. The target condition is either met or not met on the date.

Is there a short-term date that is in the future?

It is pretty common for a novice learner to set a target condition equal to the challenge. If they are over-reaching, I’ll impose a date, usually no more than two weeks out. “Where will you be in two weeks?” Another way to ask is “What will the current condition be in two weeks?”

Sometimes the learner has slid up to the date and past it. Watch for this! If the date comes up without hitting the target, then it is time to reflect and establish a new target condition in the future.

Is the target condition a step in the direction of the challenge?

Usually the link between the target condition and the overall challenge is pretty obvious. Sometimes, though, it isn’t clear to the coach, even if it is clear in the mind of the learner. In these cases, it is important for the coach to ask.

Key Point: The coach isn’t rigidly locked into the script of the 5 questions. The purpose of follow-up questions is to (1) actually get an answer to the Coaching Kata questions and (2) make sure the coach understands how the learner is thinking. Remember coach: It is the learner’s thinking that you are working to improve, so you have to understand it!

(And occasionally the learner will try to establish a target condition that really isn’t related to the challenge.)

Does the “obstacle being addressed” actually relate to the target condition?

(Always keep your marshmallow on top!)

The question is “What obstacles do you think are preventing you from reaching the target condition?” That question should be answered with a reading of all of the obstacles. (Again, the coach is trying to understand what the learner is thinking.) Then “Which one (obstacle) are you addressing now?”

Generally I give a pretty broad (though not infinitely broad) pass to the obstacles on the list. They are, after all, the learner’s opinion (“…do you think are…”). But when it comes to the “obstacle being addressed now” I apply a little more scrutiny.

I have addressed this with a tip in a previous post: TOYOTA KATA: IS THAT REALLY AN OBSTACLE?

It is perfectly legitimate, especially early on, for an obstacle to be something we need to learn more about. The boundary between “Grasp the current condition” and “Establish the next target condition” can be blurry. As the focus is narrowed, the learner may well have to go back and dig into some more detail about the current condition. If that is impeding getting to the target, then just write it down, and be clear what information is needed. Then establish a step that will get that information.

Sometimes the learner will write down every obstacle they perceive to reaching the challenge. The whole point of establishing a Target Condition is to narrow the scope of what needs to be worked on down to something easier to deal with. When I focus them on only the obstacles that relate directly to their Target Condition, many are understandably reluctant to simply cross other (legitimate, just not “right now”) issues off the list.

In this case it can be helpful to establish a second Obstacle Parking Lot off to the side that has these longer-term obstacles and problems on it. That does a couple of things. It can remind the coach (who is often the boss) that, yes, we know those are issues, but we aren’t working on those right now. Other team members who contribute their thinking can also know they were heard, and those issues will be addressed when they are actually impeding progress.

Does the “Next step or experiment” lead to learning about the obstacle being addressed?

Sometimes it helps to have the learner first list what they need to learn, and then fill in what they are going to do. See this previous post for the details: IMPROVEMENT KATA: NEXT STEP AND EXPECTED RESULT.

In any case, I am looking to see an “Expected result” that at least implies learning.

In “When can we go and see what we have learned from taking that step?” I am also looking for a fast turn-around. It is common for the next step to be bigger than it needs to be. “What can you do today that will help you learn?” can sometimes help clarify that the learner doesn’t always need to try a full-up fix. It may be more productive to test the idea in a limited way just to make sure it will work the way she thinks it will. That is faster than a big project that ends up not working.

Toyota Kata: What is the Learner Learning?

In the language of Toyota Kata we have a “coach” and a “learner.” Some organizations use the word “improver” instead of “learner.” I have used those terms more or less interchangeably. Now I am getting more insight into what the “learner” is learning.

The obvious answer is that, by practicing the Improvement Kata, the learner is learning the thinking pattern that is behind solid problem solving and continuous improvement.

But now I am reading more into the role. The “learner” is also the one who is learning about the process, the problems, and the solutions.

Steve Spear has a mantra of “See a problem, solve a problem, teach somebody.” This is, I think, the role of the learner.

What about the coach?

The coach is using the Coaching Kata to learn how to ask questions that drive learning. He may also be un-learning how to just have all of the answers.

As the coach develops skill, I advise sticking to the Coaching Kata structure for the benefit of beginner learners. It is easier for them to be prepared if they understand the questions and how to answer them. That, in turn, teaches them the thinking required to develop those answers.

Everybody is a Learner

The final question in the “5 Questions” is “When can we go and see what we have learned from taking that step?” It isn’t when can I see what You have learned. It is a “we” question because nobody knows the answers yet.

The Improvement Kata: Next Step and Expected Result

In the Improvement Kata sometimes it helps to think about the outcome desired and then the step required to accomplish it.

A couple of months ago, I gave a tip I’ve learned for helping a coach vet an obstacle.

Another issue I come across frequently is a weak link between the “Next Step” and the “Expected Outcome.”

In the “Five Questions” of the Coaching Kata we have:

What is your next step or experiment?” Here we expect the learner / improver to describe something he is going to do. I’m looking for a coherent statement that includes a subject, verb, object here.

Then we ask “What do you expect?” meaning “What do you expect to happen?” or “What do you expect to learn?” from taking that step?

I want to see that the “Expected Result” is a clear and direct consequence of taking the “Next Step.”

Often, though, the learner struggles a bit with being clear about the expected outcome, or just re-states the next step in the past tense.

While this is the order we ask the questions, sometimes it helps to think about them in reverse.

Reverse the Order

Have the learner first, think about (and then describe) what she is trying to accomplish with this step. Look at the obstacle being addressed, and what was learned from the last step.

Based on those things, ask “what do you want to accomplish with your next step?”

The goal here is to get the learner to think about the desired result. Don’t be surprised if that is still stated as something to do, because we are all conditioned to think in terms of action items, not outcomes.

“What do you need to learn?” sometimes helps.

“I need to learn if ______ will eliminate the problem.” might be a reply.

Even a proposed change to the process usually has “to learn if” as an expected outcome, because we generally don’t know for certain what the outcome will be until we try it.

Have the learner fill in the “Expected Outcome” block.

NOW ask “OK, what do you have to do to ______ (read what is in the expected outcome)?”

PDCA Outcome-Activity

That should get your learner thinking about the actions that will lead to that outcome.

A Verbal Test

A verbal test can be to say “In order to ______ (read the expected outcome), I intend to _____ (read the next step.”

If that makes sense grammatically and logically, it is probably well thought out.

Delivering the Patient Satisfaction Experience

“Our challenge is to improve our patient satisfaction scores.”

This seems to be a fairly common theme as I continue to work in the health care arena.

Background

In the U.S. at least, most major health care operations use one of a couple of major service providers (such as Press Ganey) to survey their patients, and report aggregated patient satisfaction scores to them. Those scores provide a percentile rank of how that facility stacks up against others across various categories. The scores are also made public, and often influence public funding decisions within a region. Thus, they are a big deal.

Chasing the Patient Satisfaction Numbers Doesn’t Work

Here’s the problem. More than a few times I have seen an improver working on a challenge to improve these patient satisfaction numbers. It might be something like “Achieve a 70th percentile score on ___.) with a specific score that has to do with their area.

So far, that’s not a real problem. But what happens next might be.

It is very common to focus solely on the end result, without a lot of thought into the underlying things that drive that result.

Specifically, I have seen more than a couple of cases where a manager is working to directly influence how a patient (customer) will answer the questions on the survey. They parse the question, and try to determine what this word, or that word, actually means to “the patient.” The worst case was trying to introduce fairly heavy handed scripting… “Is there anything I can do for you to be more comfortable?” into every patient interaction.

I certainly can’t speak for the population of patients, but I can say that when I pick up on a scripted phrase, I become very aware of what it is, and it leaves a disingenuous taste.

It’s About the Patient Experience

The patients’ experience is what drives how (and even if) they will answer the questions on these surveys. If their experience was overall favorable, they will be biased to give favorable replies. The opposite is even more true. One bad experience will negatively bias all of their answers.

Here’s the question I ask that sometimes stumps people:

What experience to you want the patient to have?

(If you aren’t in health care, substitute the word “customer” for “patient.”)

If your scores on “Were the staff concerned for my comfort?” are low, think about what experience would give the patient confidence that staff were concerned. Being continuously asked about it with a rote phrase probably isn’t going to do it. But leaving them parked in the hallways with no interaction might be (for example), something that creates discomfort.  (“Comfort” has a psychological, as well as a physical component.) People will put up with a lot of discomfort if they know the higher purpose. It’s hard to make the case for parking the patient in the hallway. That just says “I don’t have anywhere to take you.”

So think deliberately. If everything the patient experienced were something you were doing on purpose, because it contributed to the experience you want the patient to have, what would that look like?

Don’t worry right now about whether that is hard or not. Let go of your internal issues for a while. Just sketch out that awesome “insanely great” patient experience. You don’t have to think of every detail. What are the attributes? What is the flow, from the patient’s perspective – the sequence of events they will experience.

For example, construct a story, told from the patient’s point of view, of coming in for outpatient surgery.

What happens from the time they have their initial consultation until they are on their way home. (And what happens after they get home?) Again, don’t worry about “we can’t do that because…” stuff, we’ll deal with that later.

What experience, what story, would leave the patient with the impression that you are working as a team, that you know what you are doing, that there is a competent process at work to provide safe, effective care and actually care about their experience?

Don’t forget to include your administrative communications in this process – what phone calls do they get? What paperwork do they get? What does crystal-clear billing look like?

Build a block diagram, a story board, of the patients’ ideal flow through the system.

What would a wait-free, smooth flowing experience look like?

Learning From Disney

In Disney theme parks, they make a clear distinction between “On Stage” and “Off Stage.” Their employees (all of them) are referred to as “Cast Members.” Anytime a Cast Member is visible to guests, they are “On Stage.” They are performing. They are part of creating the story, the experience, they want the guest to have.

Meanwhile, behind the scenes, in the tunnels, off stage, are the processes required to create the “On Stage” performance. It’s a show.

The guest experience is designed. Once it is designed, it is created by the process.

Disney’s priorities (in order) are:

  • Safety
  • Courtesy
  • Show
  • Efficiency

Translated, they place putting an a good performance above being efficient. But if pushed, a cast member may break character if required to be courteous. And they will get snippy with someone who persists in doing something unsafe in spite of courteous requests.

What on Earth does this have to do with health care?

Everything. That is if you are trying to create a safe, professional and competent impression to your patients.

What is the Actual Patient Experience?

Now we have a sense of the ideal, it’s time to understand what is really happening. Again, start with the patient’s experience.

What happens at each interaction? What questions are asked? Who asks them? How often are they moved? Where and when are they waiting, and why? 

Use “typical” rather than exceptional cases here. One thing I am seeing is, yes, every case is different but in reality, most are handled within a routine.

Pay attention to the “on stage” part of your process. This is what the patient sees, and what creates their experience.

At the same time, look at the behind-the-scenes “off stage” flow to see what might be causing a less-than-ideal patient flow. For example – The patient’s experience is that he is alone in an exam room waiting, reading Time Magazine for 20 minutes. That is the “on stage” part.

Meanwhile, “back stage” you have a nurse on the phone trying to get the results of tests that were done by another provider. (This is a real-life example.)* (There was also a physician waiting on them!)

Your Processes Create the Patient Experience

(Again, substitute “customer” for “patient” and this becomes an essay for everyone.)

Your Patient Satisfaction scores are driven by the patients’ experience.

The patients’ experience is established by your “on-stage” (patient facing) process.

Your “on-stage” process is the result of your “off-stage” execution.

The people making the improvements need to be challenged, and focused on, creating a specific experience for the patient.

Linking to Policy Deployment

All of that begs the question: Who should make the linkage between process performance and patient satisfaction, because those scores do matter, in a very big way.

Let’s look at this from a policy deployment standpoint.

Certainly Administration (the executives) should be tracking their scores. From their perspective, these are an important (along with patient safety, quality, length-of-stay, financial performance, etc) aspects of how the organization is performing.

They see the overall performance and trends. And they can see how each department is performing.

But the patient’s experience is cross-functional. The patient only sees “the hospital.” He doesn’t see, and doesn’t care, that Admissions, the lab, the Emergency Department, Outpatient Surgery, Environmental Services (who cleans his room) and Radiology are all different departments. The patient doesn’t see, and doesn’t care, that “the clinic” and “the hospital” are separate legal entities.

As part of Policy Deployment, Administration should be establishing operational standards and challenging the Department Directors to meet them. Those standards are based on what Administration believes will move the needle on the patient satisfaction scores. In reality, this is also an experiment. Does this operational standard meet our customer’s expectations?

They also are making sure the Directors are working on the cross-functional interfaces between their departments. (If it isn’t the Directors’ job to do this, whose job is it?)

Key Point: Until you are consistently delivering the product or service, there is little point in trying to change things up. Set a standard, strive to meet it. Once things are somewhat stable, then you can evaluate whether your standard is adequate or not. Think about it… what is the alternative? You have random execution that is randomly working. You don’t know why. You can’t talk to people about performance until they can demonstrate consistent execution.

Summary

Your patient satisfaction scores reflect the experience of the patient.

The patient experience is the outcome of your on stage process performance.

Your on stage process performance is ultimately driven by your back stage process execution.

If you want to improve your patient satisfaction scores, establish the operational standard you want to strive for that you think will improve patient satisfaction.

Then strive to develop a process that meets that operational standard.

THEN you can evaluate whether your process is adequate.

_________

*This was an obstacle in front of a target condition focusing on hitting a standard for “In, Seen and Out” within a specific time frame for routine pre-procedure consultations. They fixed it. Patients no longer have to sit and wait while someone hunts down those test results.

Toyota Kata: Is That Really an Obstacle?

“What obstacles do you think are preventing you from reaching the target condition?”

When the coach asks that question, she is curious about what the learner / improver believes are the unresolved issues, sources of variation, problems, etc. that are preventing the process from operating routinely the way it should (as defined by the target condition).

I often see things like “training” or worse, a statement that simply says we aren’t operating the way the target says.

Here is a test I have started applying.

Complete this sentence:

“We can’t (describe the target process) because ________.”

Following the word “because,” read the obstacle verbatim. Read exactly what it says on the obstacle parking lot. Word for word.

If that does not make a grammatically coherent statement that makes sense, then the obstacle probably needs to be more specific.

 

 

Toyota Kata: Don’t Change The Target Condition Date

A target condition has three main elements:

  • An achieve-by date.
  • A level of performance that will be achieved.
  • The operational process that will be in place.

The details of the #2 and #3 can take a number of forms, but today I want to talk about the achieve-by date.

Keep the time horizon fairly short, especially at first. For a typical process that is carried out every day, I usually suggest a two week time horizon. My rationale is this: I don’t want the target condition to seem big or complex. Two weeks is enough time to understand and significantly improve a handful of steps in a complex process. It is a short enough time to keep the improver from trying to fix a complex or global issue all at once.

For example, if a process is carried out in multiple departments, two weeks is enough to try experiments in one of them, but not enough to implement a change across the whole organization. Having that time horizon helps establish the principle of small, quick, steps rather than trying to develop some kind of implementation plan.

It is important to set an actual date, not just “in two weeks” – in two weeks from when?

But here is the most important part: Once the date is set, don’t change it.

If the date comes up, and the target condition hasn’t been reached, it is very tempting to say “Just a few more days.” But once a date is slipped, the date means nothing, because it can be slipped again.

Instead, missing the date is time to step back, reflect, and go back through the steps of the improvement kata.

This is the same thing you should do when you hit your target condition.

If you hit your target way early, or miss the date, it is also time to reflect on what you didn’t understand about your current condition when you established that target. Then:

  • Confirm understanding of the direction and challenge.
  • Grasp the current condition. This is important. Don’t just assume you know what it is. Take the time to do some observations and confirm everything is working the way you think.
  • Establish the next target condition. This means erasing the old target condition, starting with a clean obstacle sheet, looking at the current condition and establishing a new target condition. I would discourage you from simply re-stating the old one. List the obstacles that you think are now preventing you from reaching the new target.
  • Pick one obstacle (an easy one, not the one you were beating your head on for the last two weeks!), and design your next experiment. Start your PDCA iteration.

Coaches: Don’t let your learner just adjust the date. There is a learning opportunity here, be sure to capitalize on it.

 

Notes and Thoughts from KataCon 2

The 2016 Toyota Kata Summit developed some interesting themes.

Even though the keynote addresses were not coordinated, one message emerged across them all.

This is about leadership development.

And by that, I don’t mean it is about further developing those in leadership positions. I mean it is about developing good thinking and leadership skills in everyone who chooses to deliberately learn. The “kata” are a structure for that learning, but learning the kata themselves is not the goal. It is a means to the end.

I know I have said this before, but now I see the beginning of a shift in the larger community, away from “kata as a problem solving tool” and toward “kata as a practice routine” for something bigger than the kata themselves.

Some Quotes and Themes

Improvement cannot be separate from management.

– Amy Mervak

This may well seem obvious. But in the vast majority of organizations, improvement is the job of the Continuous Improvement Department, or the Quality Department, or some other staff department.

If they are working on developing the improvement skills of line management, then all well and good. But if they are working directly on making improvements, then that is the problem at the root of “lack of leadership engagement.”

Intentional practice results in intentional learning.

– Amy Mervak

Put another way, without intentional practice, learning is a matter of luck. If you want your organization to actually learn a new behavior, then people and teams have to deliberately practice it until it is a habit.

What differentiates excellent organizations from their competitors is effective execution of strategy.

– Mike Rother

There is no shortage of effective models. But those models all require shifts in how people respond, especially under stress, to the unexpected.

Even in the best of times,

We want to learn something new, but we habitually follow our [existing] routines.

– Mike Rother

Our brains, and therefore we, are hard-wired to do this. And “under stress” is not the time to try to learn a new response. It has to be practiced in a space where it is safe to screw it up and learn.

This actually goes pretty deep. I have worked with a few organizations, and one in particular, where everyone adamantly agrees what changes must be made. But they don’t take active steps to get there.

Which brings us to:

40 priorities = No priorities.

Strategic priorities must be focused and formally expressed.

– Amy Mervak

It doesn’t do any good to have a Grand Vision if it is vague, or so diluted that Everything Is Important. Your job (management) is to be clear so people don’t waste their time working hard on something that doesn’t make a difference.

Although he was not present, Bill Costantino was quoted:

A long discussion is a symptom of lack of clarity on the current condition or the challenge.

– Bill Costantino

In other words, “What are we trying to accomplish here, and where are we now?” never get asked or clarified.

On Culture Change Modification

An interesting point was made about culture. Yes, we are working to shift the culture of the organization. But “change” may imply that we are changing everything. In reality, we have to consider:

  • What are we choosing to keep, maintain, enhance?
  • What are we choosing to alter?
  • What are we choosing to let go?

If these are deliberate decisions made by the team, then there is an opportunity to make purposeful adjustments, and frame them in the context of “What are we striving for?”

So perhaps the term “culture modification” is more appropriate.

Dave Kilgore’s presentation (full disclosure: I nominated Dave as a keynote) highlighted an organizational culture as the challenge for his advance team.

image

And because they are focused on creating this culture, they are making tangible progress.

Brad Frank asked the audience an interesting question.

If someone brings you a problem, there are two problems. What is the second one?

-Brad Frank

I have alluded to this in previous posts. As a leader, you have to ask “Why was my organization unable to make the correct decision without coming to me?”

Every time someone has to come and ask you something, it means you are an obstacle to their success.

– Brad Frank

Dave Kilgore emphasized the same thing and uses David Marquet’s “Ladder of Leadership” model both as a way to advance the culture, as well as a way to assess the current condition by listening to people.

I wanted to get these notes up there. I’ll cover Day 2 in another post.