Fractals In Your Practice, Oh My!

As I mentioned in the last post, I have been listening to the Audible version of the book "The New Work" by Aaron Dignon. I am really enjoying it and highly recommend it. At any rate, I continue to find inspiration and new perspectives with which to understand the Lean mindset. So, with that in mind…

Have you ever heard of 'fractals'? There are many applications of fractals, but I am most familiar with them as a kind of symmetrical art. The structure of much of nature is based on fractals. A very accurate measurement of the length of the craggy coastline of England was found using fractals. Animation software uses fractals to design mountains or forests, etc.

Wikipedia partially define fractals as:

Fractals exhibit similar patterns at increasingly small scales called self similarity, also known as expanding symmetry or unfolding symmetry; if this replication is exactly the same at every scale, as in the Menger sponge, it is called affine self-similar. Fractal geometry lies within the mathematical branch of topology.

Got that!?

Anyway, it might be easier to show you a sample of fractal art.

In this graphic, the branches and sub-branches are similar to the main tree trunk, but at decreasing scale. We could go on to draw successive smaller, similar branches on the sub-branches, theoretically ad infinitum.

Also, what is represented here as a complete tree very well could actually be a branch on a successively larger tree, ad infinitum. 

Any who...It reminded me of the process of strategy deployment (Hoshin Kanri) in our organizations. Recall that strategy deployment is the introduction, integration and alignment of our True North statement and focus areas down through the organization to the rest of the team.

Just like our fractal tree, each level of the practice should mirror the True North vision and focus area concepts, yet on a successively smaller, more discrete scope. In other words, the lead managers' level should reflect and further define the upper concepts as it affects them at their level and in their practice area. The lead reception's metrics would be similar in concept, but different in the data monitored than the lead surgery tech's metrics. Yet, both of them would be following and supporting Leadership's values.

The same is true for the frontline staff level as compared to the leadership level and manager level. They would monitor even more detailed metrics from their practice area's point view at their level. The frontline metrics support and give detail to the managers' metrics which, in turn, support and and give detail to the leadership level and the True North statement. 

Therefore, if we look at the entire practice, we can see that in each area, and at each level, the top most values are mirrored. Everyone is aligned and working towards the True North concepts from their perspective. Front line staff are monitoring those metrics that drive the manager metrics, and managers are monitoring those metrics that drive the Leadership (True North) metrics. The front line's "tree" is the same as the manager's "tree" which is the same as leadership's tree, but each appropriate for their particular level and function.Thus, Fractal Organization!

Thanks for reading. Let me know what you think about all of this.

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A Different Kind Of Rounds: Lean Daily Management

As doctors and veterinary staff, we are well acquainted with the daily ritual of morning or change of shift medical rounds. This is the gathering of hospital staff and doctors to be updated on the current status of all of the patients in the hospital for treatment, and for the dissemination of new treatment orders by the doctors in charge. This is a form of standardized work. It gets everyone on the same page in a routine and timely manner.

Lean Daily Management (LDM) serves the same purpose, but for the operations and management side of the practice.



Each morning, leadership and management go to the gemba to meet with staff of a particular area of the practice to go over that area's board. What numbers are up (and why?) and what numbers are down (and why?). Or, better yet, do the Process Behavior Charts (PBC) of the data show any "signals" or is it all just "noise?" (see also Mark Graban's book "Measures of Success") What countermeasures should be tried? Any new kaizen ideas? What, if anything, can management do to support the staff? Any evidence that standardized work is not being followed?

Sidebar: One of the two Process Behavior Charts above is showing two signals. Can you identify which chart it is and what the signals are?

LDM helps support our progress through that big PDSA cycle called hoshin kanri or strategy deployment. Remember, part of the Act (/Adjust) phase of a successful PDSA cycle is to sustain the results (for now), write new standardized work, scale up if appropriate, and start teaching to the new standard. This brings a new current state, and the next target condition is identified, initiating a new PDSA cycle of improvement.

In the figure above, the wheel has been moved up the ramp (improvement) through A3 thinking and kaizen. But, there are forces in any system that want to undo that which has been accomplished. Some call it entropy; I think of it as organizational gravity. The function of standardized work is to counter those evil forces by stabilizing and sustaining the new current state.

The role of LDM is to sustain and stabilize ("nail down") standardized work as it is currently written. LDM functions as a "checks and balance" for standardized work, which acts as a wedge to help prevent organizational backsliding. LDM is the setting aside of time on a daily basis to monitor for this potential.

So, to recap, standardized work sustains the current state, and LDM sustains the current standardized work.

Lean Daily Management meetings should take 10 to 20 minutes per day. They are typically done in the mornings, however, they need to be a scheduled, daily priority for all involved. Choose the time that’s best for your practice and team.

All extraneous interruptions should be put on hold for the entirety of the time. During the meeting, a staff member from the department or area of the practice, such as the Hospital Care team, quickly reviews the metrics, status of any countermeasures, new problems that have come up, any cross training efforts, new and ongoing kaizen, etc. with management. The staff member that leads the meeting should rotate from amongst the entire team, so that everyone gets the opportunity to lead the conversation and learn.

As is the Lean perspective, management takes on a teaching and mentoring capacity; asking questions to stimulate A3 thinking, encouraging all efforts and practicing servant leadership.

So, Lean Daily Management accomplishes several things:

1. Gets management to the places where work occurs (go to gemba)
2.  Facilitates conversation and consensus building with staff

3.  Demonstrates management's commitment to the staff

4.  Monitors the metrics that support the True North statement and KPIs

5.  Allows time to encourage and appreciate kaizen efforts

6.  Sustains and audits standardized work
7.  Creates increased engagement of the workers

8.  Show respect for workers

Thanks for stopping by. Comments, questions, and suggestions always welcome.

Also, to answer the sidebar questions, the bottom PBC is showing a signal that needs to be investigated. The first signal is the data point above the upper process limit.The second signal is three or four of the last four data being closer to one of the process limit lines than the average. In the case above, the last five data points are closer to the lower process limit line than the average. In fact, it appears that we may be trending around an entirely new, lower average, which indicates that the whole system has changed somehow. Both of these conditions should have been recognized earlier than now, if they weren't. The next step is root cause analysis and formation of countermeasures, i.e. PDSA problem solving.

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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Lean Veterinary Scoreboards

In my last post, I discussed the difference between Management By Means (MBM) versus Management by Results (MBR). MBR means only focusing on the end result of the metric or KPI (and hoping the means of getting there are efficient and value-adding processes) or focusing on the processes that lead to that result, understanding that if all of the processes are behaving as designed and under control, the end result is a reasonable assumption. Too often with MBR, dollars is the only metric.

So, I wondered, could it be possible (theoretically speaking only!) to successfully manage a practice without actually measuring any money related metrics? And, what would that look like?

In other words, without tracking gross income, average client invoice, payroll expense as a percent of gross; any money metric?

What non-financial Key Performance Indicators (KPIs) could be used to assure the monetary goals are met? The trick is to be able to identify all (or many) of the processes that are components of the money goals and to assign a metric to adequately monitor those processes.

For example, Average Client Transaction is composed of gross income divided by the number of client visits. However, these two components are the result of other systems, such as fees, reminder efficacy, ease of appointments, number of incoming calls that result in a busy signal, hours of operation, client satisfaction, medical record audits (% of services performed that get invoiced) , etc.

Here is a list of some of the non-monetary metrics I came up with in order to manage a veterinary practice:

Quality 

• Door to Doc time 
• The time from the moment the client enters the practice to the time they see the doctor; a measure of flow and, therefore, value to the client.
• Number of unscheduled follow-ups
• The number patients needed to be seen a second ( or more) time in order to get resolution of the pet's condition. Notice this is not scheduled follow-ups for additional treatment, tests or monitoring.
• % visits scheduled for recall
• % recalls made
• Response to 1st reminder
• Response to 2nd reminder
• Response to 3rd reminder
• % pets current on RV (rabies vacs)
• # client surveys returned
• # of client referrals
• % staff completely cross trained
• % dogs current on HW (heartworm) prevention
• % pets current on flea prevention
• % blood sample hemolysed
• # of blood samples requiring redrawing
• % of medical rounds performed on time

Morale

• # idea (kaizen) cards submitted
• # idea (kaizen) cards/ staff
• # idea (kaizen) cards completed
• % idea (kaizen) cards completed

Safety

• # staff injuries / time period
• # pet injuries / time period
• # of adverse anesthesia events

Costs

• # of drugs or supplies found to be out of stock
• % blood sample hemolysed
• # of blood samples requiring redrawing

Some of these probably have sub-systems or sub-processes that might require monitoring and, thus, metrics of their own.

I am not proposing that no financial KPIs be watched. Veterinary practice is a business, after all. Some financial metrics are important and necessary. (However, they shouldn't all be financially focused, either.) Maybe we have not thought about the role that systems, processes, quality, waste, and flow plays in the money numbers; the Lean mindset. Maybe we should not worry as much about the end results and concentrate more on how we get there.

What metrics you decide to monitor is up to you and your staff. Remember, Lean is about making your practice the best "your" practice it can be, not a carbon copy of the practice down the road or on the other side of the country or, even, what a management guru says it should be in order to conform to some cookie cutter model. Your True North and your team (and some experimentation) will decide what metrics are important.

There would be high level, focus area metrics for leadership to monitor, sub-system metrics that managers would monitor and, still another layer (sub-sub-system) that frontline staff would create. These metrics are all aligned and make up your management scoreboards. Incidentally, this is an example of visual management.

Scoreboards

Note that these layers generally flow down from our True North statement (they're top down, but there's input from lower levels along the way). Leadership metrics arise from our practice's focus areas. They check the destiny or course of the ship. Are we heading in the right direction?

The middle and lower level metrics, created by the people responsible for that work (with some input from their leaders), check the systems and processes that make up the focus area (leadership) metrics. Are we getting to our destination with quality, safety, effectiveness and without waste?

This flow is, in essence, what Lean strategy deployment (hoshin kanri) is all about; getting the ideals of the practice down to the floor (gemba) and aligned throughout the practice. It is everyone pulling the same rope, from the same end, in the same direction and at the same time.

The routine of management and frontline staff huddling together in a safe, honest and trusting environment every morning to discuss the scoreboards is Lean Daily Management; a topic of later posting.

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