Tag: Health Care

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Executive Rounding: Taking the Organization’s Vitals

Background:

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I wrote an article appearing in the current (October 2017) issue of AME Target Magazine (page 20) that profiles two very different organizations that have both seen really positive shifts in their culture. (And yes, my wife pointed out the misspelling “continous” on the magazine cover.)

The second case study was about Meritus Health in Hagerstown, Maryland, and I want to go into a little more depth here about an element that has, so far, been a keystone to the positive changes they are seeing.

Sara Abshari and Eileen Jaskuta are presenting the Meritus story at the AME conference next week (October 9, 2017).

Sara is a manager (and excellent kata coach) in the Meritus CI office. Eileen is now at Main Line Health System, but was the Chief Quality Officer at Meritus at the time Joe was presenting at KataCon.

Their presentation is titled Death From Kaizen to Daily Improvement and outlines the journey at Meritus, including the development of executive rounding. If you are attending the conference, I encourage you to seek them out – as well as Craig Stritar – and talk to them about their experiences.

Mark’s Word Quibble

In addition, honestly, the Target Magazine editors made a single-word change in the article that I feel substantially changed the contextual meaning of the paragraph, and I am using this forum to explain the significance.

Here is paragraph from the draft as originally submitted. (Highlighting added to point out the difference):

[…][Meritus][…] executives follow a similar structure as they round several times a week to check-in with the front line and ensure there are no obstacles to making progress. Like the Managing Daily improvement meetings at Idex, the executive rounding at Meritus has evolved as they have learned how to connect the front-line improvements to the strategic priorities.

This is what appears in print in the magazine:

[…][Meritus][…] executives follow a similar structure as they visit several times a week to check in with the frontline and ensure there are no obstacles to making progress. Like the MDI meetings at Idex, the executive visiting at Meritus has evolved as they have learned how to connect the front-line improvements to the strategic priorities.

While this editing quibble can easily be dismissed as a pedantic author (me), the positive here is it gives me an opportunity to highlight different meanings in context, go into more depth on the back-story than I could in the magazine article, and invite those of you who will be attending the upcoming AME conference to talk to some of the key people who will be presenting their story there.

Rounding vs. Visiting

In the world of healthcare, “rounding” is the standard work performed by nurses and physicians as they check on the status of each patient. During rounds, they should be deliberately comparing key metrics and indicators of the patient’s health (vital signs, etc.) against what is expected. If something is out of the expected range, that becomes a signal for further investigation or intervention.

“Visiting” is what the patient’s family and friends do. They stop by, and engage socially.

In industry, we talk about “gemba walks,” and if they are done well, they serve the same purpose as “rounding” on patients in healthcare. A gemba walk should be standard work that determines if things are operating normally, and if they are not, investigating further or intervening in some way.

I am speculating that if I had used the term “structured leader standard work” rather than “rounding” it would not have been changed to “visiting.”

Executive Rounding

Joe Ross, the CEO at Meritus Health, presented a keynote at the Kata Summit last February (2017). You can actually download a copy of his presentation here: http://katasummit.com/2017presentations/. The title of his presentation was “Creating Healthy Disruption with Kata.” More about that in a bit.

The keystone of his presentation was about the executives doing structured rounding on various departments several times a week. These are the C-Level executives, and senior Vice Presidents. They round in teams, and change the routes they are rounding on every couple of weeks. Thus, the entire executive team is getting a sense of what is going on in the entire hospital, not just in their departments.

Rather than just “visiting,” they have a formal structure of questions, built from the Coaching Kata questions + some additional information. Since everyone is asking the same basic questions, the teams can be well prepared and the actual time spent in a particular department is programmed to be about 5 minutes. The schedule is tight, so there isn’t time to linger. This is deliberate.

After the teams round, the executives meet to share what they have learned, identify system-wide issues that need their attention, and reflect on what they have learned.

In this case, rather than rounding on patients, the executives are rounding to check the operational health of the hospital. They are checking the vital signs and making sure nothing is impeding people from doing the right thing – do people know the right thing to do? If not, then the executives know they need to provide clarity. Do people know how to do the right thing? If not, then the executives need to work on building capability and competence.

In both cases, executives are getting information they need so they can ensure that routine things happen routinely, and the right people are working to improve the right things, the right way. In the long-term, spending this time building those capabilities and mechanisms for alignment deep into the operational hierarchy gives those executives more time to deal with real strategic issues. Simply put, they are investing time now to build a far more robust organization that can take on bigger and bigger challenges with less and less drama.

Results

Though they were only a little more than a year in when Joe presented at KataCon, he reported some pretty interesting results. I’ll let you look at the presentation to see the statistically significant positive changes in employee surveys, patient safety and patient satisfaction scores. What I want to bring attention to are the cultural changes that he reported:

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Leadership Development

Actually points 1. and 2. above are both about leadership development. The executives are far more in touch with what is happening, not only in their own departments, but in others. Even if they don’t round on their own departments, they hear from executives who did, and get valuable perspectives and questions from outsiders. This helps break down silo walls, build more robust horizontal linkages, and gives their people a stage to show what they are working on.

Since executives can’t be the ones with all of the solutions, they are (or should be) mostly concerned with developing the problem solving capabilities in their departments. At the same time, rounding gives them perspective on problems that only executive action can fix. In a many organizations mid-manager facing these systemic obstacles would try to work around them, ignore them, or just accept “that’s the way it is” and nothing gets done about these things. That breeds helplessness rather than empowerment.

On the other hand, if a manager should be able to solve the problem, then there is a leader development opportunity. That is the point when the executive should double down on ensuring the directors and upper managers are coaching well, have target conditions for developing their staff, and are aware of who is struggling and who is not. You can’t delegate knowing what is actually going on. Replying on reports from subordinates without ever checking in a couple of levels down invites well-meaning people to gloss over issues they don’t want to bother anyone about.

Breaking Down Silos by Providing Transparency

The side-benefit of this type of process is that the old cultures of “stay out of my area” silos get broken down. It becomes OK to raise problems. The opposite is a culture where executives consider it betrayal if someone mentions a problem to anyone outside of the department. That control of information and deliberate isolation in the name of maintaining power doesn’t work here. Nobody likes to work in a place like that. Once an organization has started down the road toward openness and no-blame problem solving, it’s hard to turn back without creating backlash of some kind within the ranks.

Creating Disruption

Joe used the term “Disruption” in the title of his presentation. Disruption is really more about emotions than process. There is a crucial period of transition because this new transparency makes people uncomfortable if they come from a long history of trying hard to make sure everything looks great in the eyes of the boss. Even if the top executive wants transparency and getting things out in the open, that often doesn’t play well with leaders who have been steeped in the opposite.

Thus, this process also gives a CEO and top leaders an opportunity to check, not only the responses of others, but their own responses, to the openness. If there are tensions, that is an opportunity to address them and seek to understand what is driving the fear.

In reality, that is very difficult. In our world of “just the facts, ma’am” we don’t like to talk about emotions, feelings, things that make us uncomfortable. Those things can be perceived as weakness, and in the Old World, weakness could never be shown. Being open about the issues can be a level of vulnerability that many executives haven’t been previously conditioned to handle. Inoculation happens by sticking with the process structure, even in the face of pushback, until people become comfortable with talking to each other openly and honestly. The cross-functional rounding into other departments is a vital part of this process. Backing off is like stopping taking your antibiotics because you feel better. It only emboldens the fear.

These kinds of changes can challenge people’s tacit assumptions about what is right or wrong. Emotions can run high – often without people even being aware of why.

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KataCon 2017 Keynote: Joe Ross

Joseph P. RossLast year I nominated Joe Ross, the CEO of Meritus Health in Hagerstown, MD to be a keynote speaker at the 2017 KataCon. I did so because I think Meritus has a compelling story.

Like many organizations, Meritus had engaged in several years of staff-led improvement focused on events and things like “A3 Training.” And like many organizations, while the individual events seemed successful, the actual long-term traction was limited.

A little over a year ago Meritus started exploring Toyota Kata as a possible way to change the cultural dynamic. The 2017 KataCon will be on the anniversary of our first training session.

In the meantime, Meritus also applied the same thinking to how they did their senior leader rounding, as well as applying the thinking shifting the way the staff interacts with patients and each other.

Joe’s talk will cover these key points and the lessons they have learned along the way.

I hope you will be there to hear his message and meet him as well some of his key people.

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NPR: Hospitals New Face Pressure to Reduce Infection Rates

This article on NPR is chiefly about the dilemma that hospital administrators are facing as escalating government reporting requirements are being tied to their Medicare payments. (For my non-US readers, Medicare is the U.S. government medical insurance program for seniors and retirees. It pays a huge portion of hospital’s revenue, and thus, its policies carry a lot of weight).

The article’s lead does a good job of summing up the issue:

Under laws in more than two dozen states and new Medicare rules that went into effect earlier this year, hospitals are required to report infections — risking their reputations as sterile sanctuaries — or pay a penalty. That’s left hospital administrators weighing the cost of ‘fessing up against the cost of fines.

So, in effect, the administrators are faced with weighing the financial impact of lost Medicare payments vs. the financial impact of telling the truth about their infection rates. This is, in my mind, yet another symptom of the General Motors style of management that is taught by every MBA program in the world.

It also suggests that there is a viable alternative of continuing to maintain the illusion that it is not a problem.

Is it a problem? Hospital infections kill about 90,000 people a year in the USA. Compare that with the 40,000 or so that are killed in traffic accidents, and you get the idea.

Add to that the fact that the patient ends up getting billed (and usually insurance pays the bulk) for the treatment of these infections.

Fundamentally this is about quality, and the problem is certainly not limited to health care. (it is just that lives are at stake)

How does your company respond when there is a known issue that is impacting quality?

If you deliver a defective product or service, do you charge your customers for the rework? This is not a facetious question. Some companies do.

Do you avoid collecting information for fear of revealing the true magnitude of a problem?

Do your workers fear bringing it up when they are directed to carry out inappropriate actions, or actions which violate the company’s written policies and procedures?

Is it OK to improvise outside of your known process in order to get the part out the door?

Back to the hospital – we know how to tackle this problem. It is merely extremely difficult. That doesn’t make it impossible. I am glad it is getting attention. I am disappointed that it takes government generated threats of visibility to get action.

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Some Healthcare Observations

A couple of weeks ago I had the opportunity to return and see my friends in the Netherlands, and I’d like to share some observations from the Lean Thinking in Healthcare Symposium I attended over there.

But that conference was on Friday. I arrived in-country on Monday morning at 7:30am. By 10:30 am I was in sterile scrubs in an operating room observing a knee replacement operation. (I was told of this agenda while on the way there, at about 9:30.) I’ve got to say it was quite an interesting experience, and here is my public, if belated, thanks to Dr. Jacob Caron, who graciously brought me into his domain. Thanks, also, to his patient for allowing me into this bit of her life as well.

The experience was fascinating, and enlightening. Here is the core value-add of a long and complex process as the patient is moved through the various stages of treatment. And at that core, things are organized, quiet, efficient. Of course it is nothing like an O.R. on television. Drama is the last thing a real-life surgeon (or patient, for that matter) wants in the O.R.

The work flow of instruments caught my eye. We all know that the surgeon asks for the instrument he needs, and the O.R. nurse hands it to him, usually anticipating his request.

But there is a return flow as well. As the surgeon is done with an instrument, he puts it down as he asks for the next one. The O.R. nurse then quickly picks it up, wipes it (if necessary), and re-orients it so she can pick it up quickly when it is needed again.

None of this is really surprising with a little thought. I imagine the tight circle around the patient is organized pretty much the same way in every operating room in technologically advanced countries. In manufacturing, we use the “like a surgeon” analogy to describe how team members who directly add value should be supported.

Later that afternoon, I was touring the ward where the orthopedic surgery ward with the supervisor.

They are working on kaizen, they have an Problem – Improvement board and do a decent job keeping track of things that disrupt work.

“No time” seemed to come up a lot as a reason for the nurses. And, from what I know of the workload of hospital nurses, this is not a surprise either.

But where does their time go?

Let’s consider that nurses are the front line. Yes, the physicians get the attention, but aside from cases like surgery, it is the nurses who actually deliver the care to the patient. In other words, though the physicians design the care, it is the nurses who actually carry it out.

So here was my question / challenge to the audience at the conference:

No operating room in the developed world would ever tolerate a situation where the surgeon had to go look for what he needed to deliver care to the patient. The surgeon’s world is fully optimized so she can devote 100% of her attention to the patient.

Yet, in those very same hospitals, all over the world, we tolerate – every day – conditions where nurses, who are also primary care providers, spend too much of their time fighting entropy, looking for what they need, improvising, dealing with interruptions – all of the things we would never tolerate in the O.R.

Why the disparity?

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British NHS Executive Talks About Lean

Lesley Doherty, the Chief Executive at NHS Bolton in the U.K. was recently interviewed by IQPC as a precursor for her being a keynote speaker at a conference IQPC is sponsoring in December (Zurich). In the spirit of full disclosure, IQPC had invited me to participate in a “blogger’s panel discussion” (along with Karen Wilhelm, author of Lean Reflections) earlier this year in Chicago.

The Chicago conference turned out to be very Six Sigma centric – in spite of having Mike Rother as a keynote. But that is history.

I want to reflect a bit about this podcast. I invite you to listen yourself- it is an interesting perspective from a senior executive who discusses her own learning and discovery. I will warn you that you may have to “register” on the web site – though you can uncheck the “send marketing stuff” box. I will also say that the interview’s sound is pretty bad, so it is hard to hear the questions, but I was able to reconstruct most of it from context.

What is interesting, to me a least, is that the methods and experiences are pretty standard stuff – common to nearly all organization undertaking this kind of transformation.

A summary of the notes I took:

They have to deliver hard budget level savings on the order of 5% a year for the next several years. That is new to them as a government organization.

They started out with an education campaign across the organization.

Initial efforts were on increasing capacity, but those efforts didn’t result in budget savings. In one case, costs actually increased. They don’t need more capacity, they need to deliver the same with less.

They have identified process streams (value streams), and run “rapid improvement events.”

Senior people have been on benchmarking or study trips to other organizations, both within and outside of the health care arena.

They are struggling to sustain the momentum after the few months after an “event” and seeing the “standard” erode a bit – interpreting this as needing to increase accountability and saying “This is how we do things here.”

“Sustaining, getting accountability at the lowest level is the biggest challenge.”

In addition, now that they are under budget pressure, they are starting to look at how to link their improvements to the bottom line, but there isn’t a standardized way to do this.

They believe they are at a “tipping point” now.

There is more, having do to with Ms. Doherty’s personal journey and learning, and knowledge sharing across organizations who are working on the same things, but the key points I want to address are above.

Please don’t think that this interview is as cold as I have depicted it. It is about 20 minutes long, and Ms. Doherty is very open and candid about what is working and what is not. It is not a “rah-rah see what we have done?” session.

As I listened, I was intently trying to parse and pull out a few key points. I would have really liked it if these kinds of questions had been asked.

What is their overall long term vision? Other than meeting budgetary pressure and “radically reviewing” processes, and “transformation.” What is the “true north” or the guide point on the horizon you are steering for?

What is the leadership doing to set focus the improvement effort on the things that are important to the organization? What does the process have to look like to deliver the same level and quality of care at 5% lower costs? What kinds of things are, today, in the way of doing that? Which of those problems are you focused on right now? How is that going? What are you learning?

What did they try that didn’t work, and what did they learn from that experience?

When you say “local accountability” to prevent process erosion, what would that look like? What are you learning about the process when it begins to erode?

The “tipping point” is a great analogy. What behaviors are you looking for to tell you that a fundamental shift is taking place?

As you listen, see if you can parse out what NHS Bolton is actually doing.

Is their approach going to sustain, or are they about to hit the “lean plateau?”

What would the “tipping point” look like to you in this organization?

What advice would you give them, based on what you hear in this interview?

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Information Transfer Fail

While the dentist was looking over my x-rays, he saw something he would like checked out by a specialist. He used words like “sometimes they..” and “might be…” when describing the issue he saw.

I get a referral. The information on the referral slip is the name of the referring dentist (which I can’t read), no boxes checked, and “#31” in the comments.

I call the specialist and start getting technical questions about what my dentist wants them to look at / look for, etc.

So the process is to use the patient as a conduit for vaguely expressed (in layman’s terms) technical information between highly trained specialists.

Sadly, I think this happens all of the time in the health care industry. It seems that there is so much focus on optimizing the nodes that nobody really “gets” that the patient’s experience (and ultimately the outcome of the process) is defined more by the interactions and interfaces than it is by the nodes themselves.

I am really not sure how fundamentally different this is from a pilot asking a passenger to find the maintenance supervisor and tell the mechanic about a problem with a plane.

The net effect is, as I am writing this, the specialist’s office is calling the referring dentist and asking them what, exactly, they want done.. a net increase of 100% in the time involved for all parties to communicate.

While the national debate is on how we pay for all of this, we aren’t asking why it costs so much (or kills more people than automobile accidents do).

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Looking at the wrong stuff: America’s Best Hospitals: The 2009-10 Honor Roll

This news piece, America’s Best Hospitals: The 2009-10 Honor Roll, originally got my attention because I hoped someone might be actually be paying attention to the things that make a real difference in our national debate about health care.

Unfortunately, it looks like more of the same.

This survey looks at things like technical capability – what kinds of specialty procedures these hospitals can perform, and their general reputation  and then ranks them accordingly.

But where are we asking about the basics?

Which hospitals kill or injure the fewest of their patients? What is the rate of post-operative or other opportunistic infection? How about medication errors? These are the things that all hospitals should be “getting right” and yet the evidence is overwhelming that most don’t. Further, nobody seems to be paying attention to it except tort lawyers.

Now take a look at this post on Steven Spear’s blog, and especially the Paul O’Neal commentary that he links to.

Tell me what makes a “good” hospital?

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Paying the Bills vs. Dealing with the Costs

House Dems want to tax the rich for health care – Yahoo! News

The health care debate in the USA is increasingly focused on how to pay (meaning who will pay) to operate a dysfunctional system with costs out of control.

I fully acknowledge that in government circles, this is about the only thing they can address.

But the real question is not “How do we pay?” but “Why does it cost so much?”

The care delivery system itself is error prone, dangerous for the patients (and psychologically dangerous for the providers). The net effect is much of the effort of the dedicated, but overworked, staff is siphoned off to deal with problems and chaos that shouldn’t be there in the first place. But there is no system in place, at least not in any operation I have ever see (including some claiming to be “lean”) that systematically detects, responds, corrects, and solves those thousands of little issues that occur every day. People seem too focused on the “big stuff” that creates lots of press.

The financial system is worse. The processing of payments and claims is inefficient (which is a kind word), error prone, chaotic, unresponsive to issues and problems, and treats the patients as though deciphering the “THIS IS NOT A BILL” statements is the only thing they have to do.

Honestly, I don’t have any ideas here. I just see that we are in a political quagmire debating how to pay for a system that shouldn’t be costing half of what it does… and it isn’t about controlling over payments or sharpening pencils on the billing.

What if one major HMO actually “got it” and became the Toyota of health care. Any takers?

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More about Overburden (Muri) in Health Care

The last post got way too long, and I wanted to get it out there. But of course, there are afterthoughts.

At a level higher than simple process chaos, overburden hits the entire organization when perceived demand is significantly greater than perceived capacity.

As I noted in the earlier post, segregating what should be routine from the true exceptions goes a long way, especially when there is work to continuously improve execution of routine things. This results in less capacity being used to process routine, and therefore, more capacity available to handle the true emergent stuff.

The next phase is to repeat the process, step by step, on the exceptions. Identify what makes them exceptions. Is there another process that can be isolated and segregated? Can you move something from “exception” to “routine” in some way?

Then look at what is left.

About 20 years ago, Philip Agre wrote a seminal PhD Dissertation at M.I.T. called “The Dynamic Structures of Everyday Life.” If you can find it, read it. This work was a major contributor to turning the science of symbolic artificial intelligence on its head. One of his conclusions was that almost everything we do is routine, and we do non-routine things in routine ways.

This thinking applies to complex, one-of-a-kind process situations. What “experience” brings to the table is knowing what things, that we know how to do routinely must be done; in what order; to gain control of the uncontrolled; and get the desired outcome.

In our heads, this is much messier than we want to believe it is. Fundamentally what we do is to try something we believe will have a certain effect, then see what effect it actually has. If the effect is the one we predicted, then we are one step closer to control and the stage is set for the next action; if not then we learn what did not work, gain a bit more understanding and try something else.

This is also how we build that thing called “experience” step by step, stretching our understanding, moving what we do not know into what we do. We do this as individuals, but it is only a truly exceptional organization that can do it as an institution. Learning is a process of prediction, testing and comparison.

The objective in these situations is to move an unknown, uncontrolled situation gradually toward familiar ground and make it into something routine.

Steven Spear quoted a health care worker that summed it up pretty well: “Air goes in and out, blood goes round and round. If either of those is not happening, we have a problem.” And in the most extreme medical emergency, the first steps are always to stabilize vital signs so that the patient will live long enough for the caregivers to understand the problem and develop countermeasures.

This is still, however, a customized sequence of tasks that should, themselves, be routine. Only the macro level varies. The more that can be done to stabilize the delivery of treatment to the patient, the less harried people will feel. They should not worry about the small things so they can pay attention to the big things.

The weak points in a complex system are the interconnections. People are not sure who should do, or has done, what. There are repeated transfers from one caregiver to another, often with far less than complete information – leaving it to the next caregiver to assess the situation all over again. Every time this happens presents an opportunity to overlook or misinterpret something that is already known.

By working very hard on execution of the things that should be routine, that much more mental capacity is made available to care for the patients. This means attacking ambiguity where ever it is found.