Lean Veterinary Strategy Deployment (Hoshin kanri)

Hoshin kanri is a Japanese word for strategy deployment. It literally translates to mean “compass management.” It is the process of introducing and aligning the organization’s True North vision down through managers to the frontline staff. It consists of a series of PDSA cycles complete with consensus building (nemawashi) and playing “catchball” along the way.

The first PDSA cycle is undertaken among leadership. It is here that the concept of True North is defined along with the four to six (typically) high-level focus areas and their metrics. 

When looked at as a whole, these few focus areas should completely define your practice. In other words, monitoring the metrics of the focus areas should give you a high-level indication of how the practice is functioning. If these metrics are improving, then the practice should be improving, also. The lower level metrics will compliment these metrics by highlighting the more detailed processes.

This a true PDSA cycle in that all of the stages (Plan, Do, Study, Adjust) are completed and what is eventually chosen is not written in stone. It is an attempt at alignment; high-level standardized work. It is an experiment. If the True North statement turns out to be inadequate in some respect, then leadership simply adjusts and starts a new cycle. A3 reports can follow the process in order to keep stakeholders up to speed.

The second cycle is between leadership (Owners, C-suite, etc.) and supervisors (lead receptionist, lead surgery techs, lead hospital tech, lead groomer, lead boarding tech, etc.). Again, consensus building is of prime interest. This is not the typical management philosophy of “command and control.” It is a typical Lean “bottom-up” endeavor with "catchball" input from leaders. Leadership introduces True North focus areas to the supervisors and, then, mentors and coaches them in order to help them to decide what True North would look like at their level.

and what processes they'll need to monitor in order to help ensure the top focus are metrics are positive. Again, this may be subject to adjustment after a period of experimentation. A3 reports are kept current.

The third cycle is between the lead staff and the frontline workers. It proceeds similarly to the cycle just described.

So, what we now have is is an overall alignment of the practice from leadership through lead techs down to frontline staff. How that looks and what metrics are monitored will vary based on the the different areas of the practice. 

For example, we might have a True North focus area of "Processes Improvement." This applies to everyone. However, at the lead and frontline level, the metrics are different between, for instance, receptionists or exam techs or surgery techs, etc. Their metrics will be determined by what that focus area means to them from their perspectives. 

If all of this is successful, then everyone, from leadership to frontline staff, should have a hold on the same rope, on the same end, pulling in the same direction and at the same time...and winning!








Mark Graban's 4 Hypotheses of Strategy Deployment

Mark has described strategy deployment as a series of four hypotheses in a series of two blog posts - here and here:

 1.  If we focus our improvement efforts and close performance gaps in our four or five True North areas, we will therefore perform well as an organization, this year and into the future.

For example, if we choose Client education, Staff development, Community involvement, Fiscal responsibility and Hospital improvement as our five True North focus areas, then we posit that if we are successful in these areas, the practice as a whole will be successful. In other words, these five areas are the best five areas to monitor in order for the overall practice to be successful. 
Remember, this is your True North statement with your focus areas for your practice with your staff and clients. 

Is this the right True North? We don't know.  But, we will start with these and experiment. If it is determined these are not the best five, we can adjust them and try again. Just like treating our patients. If one diagnosis or treatment is not working, then we “back up" and try again

What are the four or five focus areas that make up your True North and that, if successful, will results in a high probability that the hospital/clinic will be successful overall.

   2.   If we can improve and close our performance gaps in these key performance indicators, we will satisfy our need for improvement in our key focus areas, and therefore will be successful as an organization, overall.

What are the metrics (two or three per focus area) that will show that our focus areas are heading in the right direction (which, in turn, indicates that the whole practice is headed in the right direction).

Are these the right metrics? We don't know, but we'll try them for a while and then evaluate our decision. If they are the right metrics, why? If they aren’t, why not? It is important to deeply understand both of these scenarios in order to learn.

Are these metrics still relevant to your organization and staff?

3. If we actually execute and complete these top X initiatives,  projects, events and A3s, then we will make the greatest strides toward closing the key focus areas (Hypothesis  2) and therefore we'll be more successful in our strategy.

Not everything can be a high priority. It is easy to get sidetracked and pulled off task. You have already prioritized in the last hypothesis. Stay focused. Close the performance gaps in these focus areas in order to get the greatest gains, then you can start over with other focus areas. Err on the side of too few initiatives (so you can actually get something accomplished), rather than too many (and none of them get done or done right). With experience and reflection, you will get more accurate in choosing the number of areas you can tackle without the whole team becoming overburdened. 

4. We actually have the organizational capacity to complete these top X priorities in a year or a given timeframe (and with the right quality).

Do we have the capacity in terms of personnel, resources and capital to actually accomplish these priorities in a timely fashion? If not, then either we obtain them or deselect this priority in favor of another one that can be accomplished at this time.

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Kaizen

Kaizen is a Japanese word that can be translated to mean “good change,” “change for the better,” or “continuous improvement.” The methodology strives for, as Masaaki Imai says, “everybody improving, everywhere, and every day.” Toyota says the two pillars of its “Toyota Way” management system are continuous improvement and respect for people. These go hand in hand, as we are driven to improve because we respect our clients, staff, suppliers, and other stakeholders. A practice can achieve a culture of continuous improvement only by respecting and engaging everybody in improving and redesigning the way work is done.

It’s tempting for people to dream up large, expensive improvements. “We need to expand our parking lot” or “Give us better health benefits” might be two things suggested by employees. In a kaizen model, we are focused on small problems that we can solve within our span of control. Doctors and practice managers can ask staff to speak up about small problems that they encounter during the day - frustrations, annoyances, causes of delay and rework - and then ask for their ideas or “countermeasures” that could reduce waste or making things better in the practice. No idea is too small to be considered in the practice of kaizen. In fact, starting with small ideas can be a very effective way to get the process of culture change under way.

Kaizen improvements often involve low-cost and low-risk changes, putting “creativity before capital.” It’s not to say money should never be spent, but throwing money at problems or just asking for more resources doesn’t always solve problems in a sustainable way.

A kaizen process, it should be noted, is not managed like a traditional suggestion box system. Suggestion box systems have been dysfunctional for a number of reasons, including suggestions sitting in a box for weeks or months, a vast majority of ideas being rejected by management, and a disconnect between identifying suggestions and implementing them.

In a kaizen process, we start with a problem or opportunity statement followed by an idea, rather than starting with a solution. The role of management shifts from accepting and rejecting ideas to collaborating with staff to find a countermeasure that can work - solving the problem or, at least, making things a bit better. If an initial suggestion is impractical or too expensive, a practice manager should work with the employee and team to find something else to try. In a suggestion system, managers might get overburdened by having to implement everything themselves. In a kaizen process, staff and veterinarians play a major role in testing and evaluating ideas - but the practice needs to find ways to make time for improvement work.

In a simple and effective kaizen process, as explained more fully in the book Healthcare Kaizen, we follow five high-level steps:

1. Find opportunities for improvement
2. Discuss them with others
3. Implement or test the idea (following the PDSA model)
4. Document the before and after in a simple way
5. Share what was implemented with colleagues and other offices

People everywhere can be creative, and that’s true in every role. With kaizen, we understand that the people doing the work are the experts in that work. Sure, managers and improvement specialists can play a role, but that role is more of a coach and facilitator instead of telling people what do. Creating a culture of continuous improvement requires the right leadership mindsets and behaviors.

In one practice the authors visited, an employee was cut badly by a sharp edge on a cabinet. Staff said that, on about 12 previous occasions, an employee had a minor scrape caused by that cabinet. In a kaizen culture, somebody would have spoken up to point out that problem, long before a serious injury occurred. Instead of downplaying the risk or saying “Well, don’t touch that edge,” a practice manager in a kaizen culture would work with staff to implement some countermeasure, such as putting a foam piece over the edge, that would reduce the risk of injury.

In a kaizen model, this problem and idea would be written down on a simple, standardized card. The card would be displayed visually and transparently on a bulletin board. The idea would be discussed informally or in a team huddle. Ownership would be assigned to an employee or small team, and they would then update the status of the improvement on the card. As improvements are implemented, if successful, protocols would be updated as needed and a simple “before and after” summary would be created and shared across the practice. In larger organizations with multiple practice locations, the “cloud” or software systems could be used to share and spread ideas more widely. If a practice in Dallas finds a problem and solves it, the other practice location in Fort Worth might benefit from seeing what was done. Sharing and spreading ideas can help prevent each office from having to reinvent the wheel. Or, seeing the ideas implemented by others might inspire our own.

Our view is that a practice with a solid culture of continuous improvement, along with simple methods for facilitating and tracking ideas, would outperform clinics where staff and doctors are told to just show up and do their jobs. As Toyota and Lean healthcare organizations say, “Everybody has two jobs... to do the work and to improve the work.” Kaizen will lead to better client service and outcomes for patients, a better workplace, and better financial results for the practice owner.

Read more in the book Healthcare Kaizen by Mark Graban and Joe Swartz.

Standardized Work

Mary is licensed veterinary technician. When a shocky, weak puppy was presented, Dr. A tells her that a PCV and blood glucose is always indicated in cases such as this and should be performed even before the doctor sees the pet. Two weeks later, a similar case presents and Mary performs both tests immediately upon intake. Dr. B, the doctor on duty, pulls her aside and angrily instructs her to never perform any blood tests without orders from the case doctor.

Unfortunately, we have all been witness to such scenarios. The doctors may not realize these type of situations are occurring.  But, the effects on staff can be far reaching.  It engenders feelings on the part of staff of anger, resentment, confusion and loss of confidence in management.

In the Lean method, “standardized work” is our definition of the best way to do work in a way that ensures safety and quality, while driving the best productivity and minimizing delays for the customer. It is the foundation for continuous improvement and employee empowerment. It is necessary for “flow” and “pull”. Standardized work gets everybody on the same page and reduces employee anxiety. When processes are in chaos, they must first be brought into some semblance of stability. What is the best way to do our work? This stability (and ongoing improvement) is achieved through standardized work. Once there has been some degree of order established, then the processes can be improved by applying other Lean methodologies, such as kaizen.

Standardized work is not the same as “standard” work. Standard work might imply written in stone, inflexible, inappropriately detailed or micromanaged. Standardized work is broader in concept. Think in terms of simple algorithms or checklists. For example, requiring the drawing of a blood sample for a routine health profile into a 3 cc syringe as opposed to a 5cc syringe would, in most cases, be too detailed for standardized work. However, in the diagnosing of the cause of a “red eye,” it is important to specify that the Schirmer tear test be run prior to staining the cornea or using any topical anesthetic drops in order to check for glaucoma. “Canned” computer estimates might be thought of as another form of standardized work in that they do not dictate a specific recipe, but suggest considering the need for such drugs or services such as antibiotics, hospitalization, analgesics, diagnostic tests, etc. They act as a reminder.

When we create standardized work documents, it’s important to ask what should be standardized and to what level of detail. What problems are solved or prevented by having standardized work? What goals are being accomplished? The goal is not to have standardized work. The goal is better performance in all dimensions and a better workplace for all. Standardized work is a “means to an end”, not a raison d’etre. As mentioned above, the reason for standardized work is to start the process of improvement, which ultimately is for the purpose of increasing quality and value for the client, the “holy grail” of Lean.

Chaos must be brought under some control with Standardized Work before Lean "tools" can improve processes. Note that the blue dot becomes increasingly evident as abnormal as the process is first standardized and then improved. Lean helps identify problems.

But there are also some important ramifications. Like most of the methodologies that make up TPS, standardized work is designed by consensus with staff.  Consensus means obtaining ideas for problem solving from all stakeholders, including staff. It comes from the mindset that all workers have valuable input, knowledge and skills that are assets to the organization in problem solving. It is a sign of respect for workers. It does not mean that all opinions are valid and must be taken or that each individual gets to do the work however they want. Toyota has long emphasized that standardized work must be created by those who do the work. It is not dictated by managers or experts.

By involving workers in this way, a vital resource is utilized and leads to increased “buy in” and engagement. It improves communication and reduces anxiety on the part of everyone of not knowing what is the correct (preferred, agreed upon) way or doing something incorrectly. It helps insure that vital information is available even if a key staff member is absent or has moved on. Plus, standardized work becomes the basis for a formal, in-house training program and is the foundation for continuous improvement.