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.

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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.

Toyota Kata in Health Care

I’m about four months into helping a major regional hospital develop a solid foundation for applying the Improvement Kata and Coaching Kata to learn “improvement thinking.”

They now have active improvement boards running in pre-op, post-op, surgery, radiology, the lab, the emergency department, the cardio-vascular floor, medical-surgery floor, ICU, cardiac rehab, billing, admissions, case management, and supplies. I think that’s everything going right now.

Several of these departments have more than one board, and a few are beginning to get started spontaneously.

We are starting to see the culture begin to shift in many of these departments. Staff are getting engaged in improving the work flows, administration team members are more engaged with the staff.

Directors and managers are starting to reach across organizational boundaries to deal with obstacles and problems at the departmental interfaces.

And the organizations are starting to shift how they talk. When confronted with a list of problems, leaders are starting to ask “OK, which one are we addressing first?” Leaders are asking “What do you expect to happen?” and “What did we learn?” when talking about actions. They are working to engage thinking in their organizations vs. just giving direction.

Is it all rainbows and unicorns? Of course not. But the effort is clearly being made, and it shows. My overall process coaching is getting much more nuanced, because they are “getting” the fundamentals.

OK, so what did we do?

We started out with two weeks of pretty intense “kick-start.” One week was half-days of training and simulation (with a morning and afternoon group), getting a feel for the rhythm of the improvement kata, and a taste of the coaching kata, and culminating with the first round of improvement boards getting set up with at least a direction, if not a clear challenge.

We deliberately did not use industrial examples. And now that I’ve done it a few times, I can incorporate more health care language and examples into the sessions, which just makes it easier.

Week two was pairs of learners/coaches being coached through grasping the current condition, establishing a target condition, and the first couple of PDCA cycles / experiments.

But what made it work is they kept at it.

The next month, we did it again. We coached the established boards to tighten up their game, while establishing a series of new ones.

Because they had kept at it, the first round of boards now had a routine for their improvement cycles and coaching. And once there is a pattern, then we can work on improving it.

What I am learning.

Just get them going, then leave them alone for a while to keep at it. That lets the team establish a baseline routine for how they are practicing. Then I can come back periodically and propose adjustments on one or two items that let them step it up to the next level.

I am finding this much more effective than demanding they get it perfectly from day one. There is just too much to think about.

Establish a target condition, have them practice to that pattern, grasp the current condition, establish a new target… for the team’s practice. Get the improvement engine running, even if roughly, then work on tuning it for performance.

To be clear, this is my normal approach (and it is different, I am told, from what a lot of others try to do), but I am getting a lot of validation for it here.

Results

A member of the administration (leadership team) who is actively coaching shared this chart with me today. I have “sanitized” it a bit. Suffice it to say these three lines represent the percentage of deliveries of three separate (but related) processes within or before the target turn-around time of 30 minutes. Their challenge is to turn 95% of them around in 30 minutes or less.

The vertical red line represents when they started applying the Improvement Kata to this process.

Otherwise, the picture speaks for itself.

image

They have recognized that there is no silver bullet here. Rather, there have been dozens (or more) of changes that each save a little bit of time that is adding up.

As one of my early Japanese teachers said “To save a minute, you must find sixty ways to save a second.” and that is exactly what they are doing here. They are finding a minute here, a few seconds there, and anchoring them in changes to the way they organize the work flow.

Lab Team: “Way to go!”

Developing Cross Functional Responsibility

The Challenge

It’s a typical staff meeting. The function heads are around the table with the boss. One of them describes a hiccup or problem he is encountering that is outside of his control – it originates in another department for example.

An action item gets assigned in the meeting, and we move on to the next topic.

Good to go, right? Isn’t that the boss’s job?

Let’s expand the role of the boss a bit. Rather than being the conduit of all information, isn’t the role really to “Ensure cross-functional coordination is happening?”

If these meetings are weekly, there is weekly cadence to this kind of coordination, meaning if the issue comes up immediately after a meeting, it is a week before a decision is made. On average, it is a few days.

Let’s look at the nature of the language being used. The implied (but often unstated) question being asked by the function heads is “What do you want me to do?” The even worse implication is “I’ll work on cross functional issues when I get an action item to do it.” Not exactly teamwork.

Here’s another example.

Three functional managers all work in the same building… actually in the same open room. The building isn’t even that big. You can find anyone who is anywhere in the building in less than 5 minutes, just by standing up and walking around.

Their common boss is a in another city, a couple of hours away.

As he talks to these functional managers, they tell him of issues. But they haven’t talked to their counterpart who is 20 feet away. They are expecting the boss to do that. To say this exasperates the boss (who “gets it”) is an understatement.

In yet another organization, we are talking to various department directors about process improvement. Nearly every one of them cited problems in other departments as disruptions to their processes.

These Directors are implicitly (and sometimes explicitly) expecting the CEO and Executive Team to issue directives to the other departments to fix these problems. The problem comes in when the Executive Team accepts the “assignment” and facilitates the communication. Now it’s their job.

Here is the question that surfaced in this organization: The managers were responsible for organizing and managing the processes that are internal to the department. If the Directors aren’t the ones responsible for that cross-departmental coordination… whose job is it? And if it is someone else’s job, what value are the Directors actually adding by managing the managers’ management of the internal processes, and commiserating about the problems from other departments?

All of these cases are the consequence of a management process that sends reports up, and sends decisions down. This develops a deeply rooted unconscious set of habits that are hard to change even when all agree it should be changed.

What Doesn’t Work

Saying “We need to do a better job talking to each other” isn’t going to work. Even saying “You need to talk directly to Dave about that” really doesn’t work because:

  • It is still telling him what to do.
  • The behavior repeats for every instance because “Jim” is still habitually coming to the boss for direction.

What We Are Trying

The objective (challenge) is to get the boss out of job being the sole conduit for cross functional communication. We want these guys working as a team.

In one of these cases, the boss and I took a page from David Marquet’s book, and thought it might help if he (the boss) made it clear that he is going to refuse to be the intermediary in these conversations. Now… how does he create the environment where this cross-coordination is happening as a matter of routine?

David Marquet’s “Ladder of Leadership” model may be useful here.

Grasp the Current Condition

“Start with Awareness, and Just Listen”

         – David Marquet, author “Turn the Ship Around”

imageTake a week and just listen to the words people use when talking about cross-functional problems. Are they simply stating the problem and hoping the boss will pick up doing something about it – and tell someone what to do?

Make a tick-mark on the ladder diagram for the level of each conversation.

Are they implicitly or explicitly looking to be told what to do? (Telling Jim to “Talk to Dave” or even asking “Have you talked to Dave?” is telling them what to do.)

Where is your center of mass?

“Tell me what to do” is the bottom rung. Your own current condition may well be different, but if you have read this far and this still feels relevant to you, it likely isn’t much different.

Establish the Next Target Condition

What words does the boss want to hear when one of those managers is letting him know what is going on? Not in the ideal situation, but at the next level – up one or two rungs.

For example, instead of saying “We’ve got this problem from Dave’s department.” and waiting to be told “Have you talked to Dave?” what does the boss want to hear from this department head?

Maybe “We’ve got this problem from Dave’s department, and I intend to talk to Dave to confirm that he understands what we need from him.”

Apply Rapid Iterations of PDCA

OK, now that the boss knows what words he wants to hear, how does the boss change his response so when he hears “We’ve got this problem from Dave’s department” the boss’s response drives thinking and initiative back down the chain.

Stealing another line from Marquet, maybe the boss says “OK, what do you think I’m thinking right now?”

“ummm… I’m thinking you want me to go talk to Dave about this.”

“Great. What do you expect to happen?” and then “OK, when can you let me know how it actually went, and what you learned?”

Ideally the boss wants to continue this process, setting successive targets until he hears “We had this problem, but Dave and I worked out a solution, and this is what we’ve done.”

or they only come to the boss with a problem that requires the boss to cross-coordinate with one of his peers, but they come with a solid recommendation.

Step by step.

Never give up on your people.

“We Need To…”

When working with large organizations, I frequently hear a surprising level of consensus about what must be done to deal with whatever challenge they are facing.

Everyone, at all levels, will agree on what must be done. They will say “We need to…” followed by statements about exactly the right things, yet nobody actually does it. They just all agree that “we need to.”

I even hear “We need to…” from very senior leaders.

It’s a great car, I wish we made more of them.

– Attributed to Roger Smith, CEO of GM, following a presentation on the Pontiac Fiero.

I can’t come up with a clever name for this, but it is really the opposite of Jerry Harvey’s “Abilene Paradox” where a group embarks on an activity that no one actually wants to carry out. In this case, a group doesn’t take action toward something they all agree must be done.

I would contend that “We need to” spoken to no one in particular is an artificial substitution of the word “we” that does not actually include “I.” Substitute “they” for “we” and you hear what is really being said.

“They need to…”

“Somebody needs to…”

This isn’t clarity. It isn’t accountably. It is a wish.

In Turn the Ship Around, David Marquet challenged (actually ordered) his crew to never use the word “they” to refer to any crewmate on the submarine. This shift in language was an early step toward shifting the teamwork dynamic on the USS Santa Fe. Marquet comments “We don’t have teamwork. We have a rule. You can’t say ‘they’.” but the truth was that the linguistic shift precipitated a shift in the behavior and then the underlying thinking.

This week we asked the question: What small change to their language could we challenge a leadership team to make that would shift the dynamic of “We need to” from general, ambiguous statement toward taking a step to fix it.

What should follow “We need to…” to turn it into accountable language?

One suggestion that came up would be to follow “We need to…” with “…therefore I…

By making that thinking explicit, we might tacitly flush out “We need to, therefore I intend to wait for someone to tell me to do something.” or “We need to, therefore I am going to hope it happens.” or “We need to, but there’s nothing I can do.”

Realistically, no one would say those complete sentences on purpose, but a struggle to come up with something more concrete might trigger some reflection on the underlying thinking.

Maybe we can turn “We need to, therefore I…” into describing one step the speaker can take in his or her organization without seeking permission*. There is always something that can be done.

This doesn’t need to be scripted or literal. It might just take a self-empowered voice to ask “We all seem to agree on what must be done. What step are we going to take, today, to move in that direction?”

Action Step: Challenge your team when you hear “We need to.” Are you talking about an anonymous “they” or taking a concrete action step? Who, exactly, is “we” if doesn’t include “me”?

Never give up.

_________

*Keeping in mind that “without permission” does not always mean “I have the authority to do it.” It just means “It is the right thing to do, so I’m going to do it.”

The Improvement Kata PDCA Cycles Record

The improvement kata has four major steps:

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Those steps provide a structured pattern to enable consistent practice until they are unconscious and natural.

In the fourth step, “Iterate Toward the Target Condition” we have a form, called the PDCA Cycles Record that provides an additional level of structure for the improver / learner and the coach.

This is the PDCA Record form from Mike Rother’s Improvement Kata Handbook (click the link to go to his download page):

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The columns in the form correspond with the “5 Questions” that are part of the Coaching Kata.

The intent is that as the coach asks the questions, the learner points to and reads his answers. In the 5 Questions, it is the “Reflection” (on the back of the coaching card) and question #4 that address the PDCA Cycles Record.

Let’s look at how this form structures the learner’s process.

The very first experiment or trial that the learner sets up is based on his understanding of the current condition and the obstacles he is facing. He selects an obstacle, decides what he should do first, and fills that step in Column 1 “Date, step & metric.”

He must think a bit and also fill in “What do you expect?” and describe what effect he expects to have on the process (or what he expects to learn) as a result of taking that step.

Then he hits the yellow bar in the middle of the form. It says “Do a Coaching Cycle.” Do not pass this point without checking in with your coach.

The coach, this time around, is going to ask the 5 Questions, but skip the reflection step, because there is no previous step to reflect on. The coach is (or should be) looking for things like (these are by no means inclusive, rather they just came to mind as I’m writing this):

  • Is the obstacle actually something which must be worked out, or something which must be learned to reach the target? Or is it just a “to do” item? He may ask some follow-on questions to clarify the connection.
  • Is the “Next Step” actually something which addresses the obstacle? Does it reflect a step into “unknown territory” that includes learning?
  • Is the expected outcome a logical consequence of taking the step being proposed? Does it have something to do with the obstacle?

By having the learner write down his intent prior to the coaching cycle, the coach can see how the learner is thinking without biasing that process. He can see if the learner is off track. If so, it’s pretty simple to erase, or even scratch out, the planned experiment and revise during the coaching session.

But either way, as  coach, I want to see the learner’s best effort before I influence or correct it. That is MY process for “grasping the current condition” and even checking the result of a previous experiment on my part by emphasizing something specific during the last coaching cycle.

Once the learner is good-to-go, the NEXT yellow bar says “Conduct the Experiment.” This is the “DO” of PDCA.

Once he is done, the learner is expected to write down his observations in the “What Happened” column, then reflect, and write down what he learned in the “What We Learned” column.

THEN, based on what he learned, plan the next step. So, move down a row, and fill in block #1 with the next step, and block #2 with the expected result.

Then he hits that yellow STOP bar again. This time the coach is going to ask the reflection questions on the back of the card – reviewing the last step and expectation, and then covering the new information: What actually happened; What did you learn; Based on that, what is your next step; and what result do you expect from taking that step?

My job as the coach is to make sure the learner can connect the dots. I want him to write all of that down before I talk to him.

I have to see the learner’s “actual condition now” before I can effectively coach him.

Why Am I Talking About This?

I have run into a few cases now where I have gone into an organization with some prior training or experience with Toyota Kata. They have asked me in to do some additional training, or coach them to the next level because they think they are “stuck.”

In a couple of those cases, I have observed a deliberate* practice of filling out the blocks on the PDCA record during the coaching cycle. Their intent seems to be for the learner to be guided by the coach as he fleshes out what actually happened; what was learned; the next step or experiment; and what is expected and writes those things on the form.

This is very effective if the intent is for the learner to “get it right.”

But from a coaching standpoint, I feel (and this is my opinion) that this practice deprives me of information I need to ascertain how the learner would do it on his own.

I also believe it runs the risk of building a dependency on the coach, and shift the psychological responsibility off the learner – it is easy to fall into the “tell me what to do” trap unless the coach is experienced enough to avoiding “leading the witness” during the coaching cycle.

In most organizations, the hierarchy that likely exists between the coach and the learner has a deeply seated habit of the boss having the answers. I want to avoid reinforcing this dynamic.

A Caveat for Brand New Beginners

When the learner is going through the Toyota Kata steps the first few times, he won’t know what to do. It is completely appropriate for the coach to demonstrate, and guide, the learner through his steps. But the organization should not confuse this effort with the intended pattern of the improvement kata.

As soon as the learner has shown that he understands the intent of the process steps, it is time for the coach to step back and let the learner try it on his own. “Take a few swings” to use a spots metaphor.

That gives the coach the best opportunity to see where he needs to focus his effort. And the PDCA record may well be scratched out, revised, or rewritten in the process. It’s OK for it to be messy. That’s what learning looks like.

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*This is different from a case where the learner simply isn’t prepared for the coaching cycle and hasn’t filled in the forms or even thought about what to put on them.

How Do You Measure Toyota Kata?

I’ve run into a couple of cases where there is an initiative from a corporate continuous improvement team to “implement Toyota Kata.”

Aside from trying to proscribe each and every step of the way (which runs counter to the entire point of discovering the solution – “you omitted step 7b”), they also expect reports of metrics related to the “implementation.”

Things like:

  • Number of coaches.
  • Number of coaching sessions.
  • Number of active improvement boards.
  • Scoring learners on a dozen or so categories of specific attributes for their coaching session.

Then there are bureaucratic reporting structures demanding that this information (and much, much more) get dutifully filled in and reported up to the continuous improvement office so they could monitor how each site is progressing (often from across an ocean).

I’ve seen this before.

I’ve seen companies try to count kaizen events, and quantify the improvements for each one to justify the payback of the effort.

Similarly, I’ve seen top-level corporate leadership teams struggle to determine how to measure, at a glance, whether a site was “doing lean” to get their results (or getting the results by some other means(?) that were less appropriate).

I’ve seen companies try to manage quality by having the quality staff prepare and submit elaborate monthly reports about what was, and was not getting done based on what they felt was important.

I lump all of this under “management by measurement.” I think it is often a substitute for (1) trusting middle management to tell the truth and (2) actually talking to people.

What’s The Alternative?

First we need to work out what we really want people, especially middle managers, to actually do. What would full participation look like if you saw it?

For example, one company I work with has had a problem where middle managers send their people to internally run “kata training,” then say they have no time to coach their people, give them ambiguous or shallow challenges to work on, and generally look at the training as someone else’s responsibility.

OK, what do you want them to do?

In their book Switch, Chip and Dan Heath talk about “scripting the first moves” so someone who is unsure how to begin doesn’t need to expend limited psychological energy figuring out how to start. We want to get them going. We don’t need to lay out the entire process (that will end up being different for everyone) but we can create some clear rules or guidelines for getting started.

From the Switch Workbook on the Heath Brother’s web site:

Be clear about how how people should act.

This is one of the hardest – and most important – parts of the framework. As a leader, you’re going to be tempted to tell your people things like: “Be more innovative!” “Treat the customer with white-glove service!” “Give better feedback to your people!” But you can’t stop there. Remember the child abuse study [from the book]? Do you think those parents would have changed if the therapists had said, “Be more loving parents!”  Of course not. Look for the behaviors.

Asking that question, in terms of what they would actually see their middle managers doing, we came up with three general actions:

  • Work with their learner / improver to establish a clear challenge for them.
  • Commit to regular coaching cycles with their improver.
  • Commit to receiving 2nd level coaching during those sessions (so they can learn as well).

The question then becomes what mechanism can the organization put into place to encourage that behavior vs. just sending people to the class and not following up in any way.

It is easy to tell people what they shouldn’t do. It’s a little tougher to tell them what they should do.

In this case, we discussed establishing prerequisites for sending someone to the class. But these prerequisites are for the organization sending the participant to the training, rather than just the person attending the class.

It is the sponsoring manager who must commit (perhaps even in writing) to ensuring there is an improvement challenge; to establishing a regular coaching cycle; and to welcoming 2nd level coaching.

Perhaps this would be a commitment to the advance team who becomes a bit of an admissions committee – ensuring the support structure is there before we commit to taking someone on in the class.

We discussed taking a copy of the organization chart and putting dots on it where they had active improvement boards and coaching relationships. That would highlight which organization groups were developing their own people and which ones were doing less of it.

We discussed inviting the middle managers who have sent people to the class but, today, are not supporting, to come to the advanced team with a plan – perhaps a similar commitment – for their renewed participation. But no one would be required, because you can’t force anyone to learn something. Put your energy toward the people who want to learn. Trying to get participation from people who don’t want to do it just frustrates everyone.

And finally, create a mechanism for someone inside a non-participating organization to raise their hand and ask for help with their own development. Don’t punish the entire organization because their boss won’t play.

Now you are talking about mechanics, about actions that have testable outcomes: Experiments that can be set up and tried, improved, and iterated in the direction of something that works for your organization.

It is more work than just measuring people. And it doesn’t work every time. But it works more often than something that never works.

Output vs. Takt Time

The team’s challenge is to reach steady output of 180 units per hour.

Their starting condition was about 150 per hour. Their equipment and process is theoretically capable of making the 180 per hour with no problem.

They calculated their takt time (20 seconds) and established a planned cycle time of 17 seconds.

Some time later, they are stuck. Their output has improved to the high 160s, but those last 10-12 units per hour are proving elusive.

This is the point when I saw their coaching cycle.

Looking at their history, they had set a series of target conditions based on output per hour. Their experiments and countermeasures had been focused on reducing stoppages, usually on the order of several minutes.

“Does anybody have a calculator?”

“Divide 3600 seconds by 180, what do you get?”

“20 seconds.”

“Do you agree that if your line could reliably produce one module every 20 seconds that you would have no trouble reaching 180 modules per hour?”

Yes, they agreed.

“So what is stopping you from doing that?”

They showed me the average cycle times for each piece step in the process, and most were at or under 15 seconds. But averages only tell a small part of the story. They don’t show the cumulative effect of short stoppages and delays that can cascade through the entire line.

The team had done a lot of very good work eliminating the longer delays. But now their target condition had to shift to stability around their planned cycle time.

Performance vs Process Metrics

This little exercise shows the difference between a process metric and the performance metric.

Units-per-hour is a performance metric. It is measured after the fact, and tells the cumulative effect of everything going on in the process. In this case, they were able to make a lot of progress just looking at major stoppages..

Stability around the planned cycle time or takt time (you may use different words, that’s OK) is a process metric.

It shows you what is happening right now. THIS unit was just held up for 7 seconds. The next three were OK, then a 10 second delay. It’s those small issues that add up to missing the targeted output.

The team’s next target condition is now to stabilize around their planned cycle time.

Since they averaged their measurements, their next step is to (1) take the base data they used to calculate the averages and pull the individual points back out into a run chart and (2) to get out their stopwatches and go down and actually observe and time what is really going on.

I expect that information to help them clarify their target condition, pick off a source of intermittent delay, and start closing the remaining gap.