Circle of Success Associates: a lean, six sigma business blog

Public Healthcare Problems being addressed

With new health problems coming to the forefront, public-health is tackling a broad range of challenges from smoking, obesity, and drinking to mental and sexual health. We also need to focus specifically on tackling inequalities in health. On average we are living healthier and longer lives, health and life expectancy are not shared equally across the population. Despite overall improvements, there remain differences in health between those at the top and bottom ends of the social scale. Mental health problems are becoming common in areas of deprivation. Such inequalities in health are not acceptable. Our fundamental aim must be to create a society where more people, particularly those in disadvantaged groups or areas, are encouraged and enabled to make healthier choices.

The time is right for innovative and fresh thinking in improving and supporting healthier communities. While the majority of the public health departments, along with various community-based healthcare providers are racing to meet the Healthy People 2010 and aligning 2020 objectives, disasters such as Hurricane Katrina have brought concerns related to lack of systematic processes to address disruption in continuity of care to the forefront. With additional complexities in healthcare, public health administrators are turning their focus to find novel solutions to meet the needs of their communities.

Opportunity to make a Practical Difference in Public Healthcare

I have the privilege and honor to work with Dr. Virginia A. Caine, and the Health & Hospital leadership team, these past three years. The Health & Hospital Corporation has two primary areas of responsibility:

• Hospital Healthcare, and
• Public Healthcare

Most of my time was spent working and facilitating process and change management improvements within the public health departments. My basic knowledge of public health at the beginning was almost nonexistent. To understand the various aspects of public health, I needed to gain hands-on exposure and experience within the various departments. I spent time in the following departments observing, listening, and learning from both patients and employees:

• Communicable & Chronic Disease Control
• Dental Health
• HIV/AIDS Prevention / Clinic
• Immunization
• Maternal and Child Health
• Food Safety / Water Quality
• Housing and Neighborhood Health
• Communicable & Chronic Disease Control
• Mosquito, Rodent and Environmental Control
• Occupational Health, and
• Adolescent Care Clinic

It has inspired me to think and view differently the various aspects of public health in the United States and world-wide. It forces you to put yourself in the patient shoes, and begin to gain an understanding of the magnitude of work, and appreciation of healthcare practices, knowledge of obstructions and consequences to care, and the significance stakeholders have in the healthcare environment.

The growing public interest in healthcare means that there are now real opportunities to make a practical difference. Healthcare is becoming more and more prominent in news headlines, TV programs, magazines, and in our everyday conversations.

Encouraging a Cultural Change in Healthcare

Evidence pointing to the applicability of a cultural change towards a continuous improvement methodology and related best practices within healthcare has been steadily mounting over the past few years. As healthcare continue to face serious challenges in the years ahead, including Federal and State compliance, disaster readiness, costs, shifting demographics, and never-ending resource constraints, healthcare providers will increasingly seek solutions that produce verifiable results.

Opportunities for improvement abound throughout healthcare. The appropriate implementation of Lean / Six Sigma can create a clear path for solutions that will have a positive impact on the cost and quality of community health. Such methods help to identify opportunities for improvement, highlight non-value-added steps, and organize the workplace for peak efficiency. Combined with change management and leadership systems, they can empower people to work together, to apply common methods and to develop sustainable solutions based on solid evidence rather than intuition or organizational politics. Organizations that have adapted such an approach give form to the idea of constantly striving for perfection.

Key Components for Continuous Improvement in Healthcare

To address the above-mentioned needs and gaps within the arena of public health, key stakeholders, such as Dr. Virginia Caine recognize that the time is right to find better, data-driven solutions to improve operations, to develop a skilled and motivated workforce, and to improve health outcomes of their constituents.

Lean/Six Sigma is a continuous quality improvement philosophy rooted in the principles of commitment, clarity, and consistency. Research demonstrates that implementation of Lean/Six Sigma in the manufacturing industry and more recently healthcare facilities such as hospitals has resulted in enhanced customer satisfaction, efficient workforce, decreased errors, and financial savings.

Through implementation of Lean/Six Sigma principles in a public health setting, Dr. Caine is proposing to create a data-supported framework that can be tailored by various public health departments, community-based organizations, and other governmental entities nationwide to effectively and efficiently address their organizational needs and as well as the needs of their constituents. The key components of this framework are:

• Lean/Six Sigma is about results, not belts and statistical tools. Lean/Six Sigma is not a business strategy; it is a powerful enabler of executing on business strategy. Too many organizations focus on education and calculating the number of Kaizen Events, Black Belts and Green Belts they need based on their revenue and headcount. It’s all about eliminating problems and focusing on continuous process improvement through active employee participation. Lean / Six Sigma methodology and statistical tools are the means, not the ends.
• Strategic Improvement is a Core Competency. It all looks so easy and logical, but the ability to define, organize, and lead a major initiative like Lean / Six Sigma is a skill that most organizations do not have internally by osmosis, and they underestimate the difficulty of launching and deploying a strategic improvement initiative of this magnitude. It takes a huge, long-term commitment to define and organize a strategic improvement initiative and then integrate strategy, leadership, execution, the right methodologies, and permanent culture change.
• Leadership, strategy, infrastructure, and deployment are most critical. Lean / Six Sigma leadership represents 80% of the success factor, while the statistical tools and belts themselves represent the other 20%. Leadership is the turbo-charged engine that drives a successful Continuous Improvement deployment. Many organizations skip the most important element of improvement – The Strategy and Deployment Plan. Organizations tend to skim over this process and dive into the methodologies and tools. In the absence of a well-defined Continuous Improvement Strategy and Deployment Plan, activities are “perception-driven” vs. “fact-driven,” and not focused on strategic gaps and root causes of poor performance.
• Knowledge Transfer & Sustainability. It is necessary for the organization to be fully self-sufficient. The Lean / Six Sigma methodology and infrastructure are deeply ingrained within the culture and management has the philosophy of continuous improvement

Intended Improvement and Results

Lean/Six Sigma is an integrated approach to designing, doing, and improving the work of groups of people working together to produce and deliver goods, services, and information. The result is to create a deployment model that can be tailored and utilized throughout community healthcare. The goal is to identify and link key process indicators that impact outputs and affect community health.

Examples:

• Changes made to reduce lead time in dental patient registration have delivered improvements in quality of treatment that can result in a reduction of cardiovascular-diseases, increased capacity and customer satisfaction.
• Community infant mortality rates reduce as a result of corrections made to miss-coded vials or wrong labeling of vaccines. These process improvements enhance overall immunization rates, and reduce vaccine shortages.
• Elimination of duplicate information, inaccurate data, and misplaced documents help nutritionists prescribe and educate patients on proper nutritional plans that reduce obesity, tobacco use, and reduce infant mortality.
• Improvements in housing inspections by reducing inaccurate information, missing files, and to standardized interpretation of city codes, results in a reduction of violent crime, lead poisoning, and improved efficiencies in Environment and Rodent Control agencies response time.

This framework will also include policy-related recommendations that will assist similar organizations nationwide to develop and implement tailor-made strategies within their day-to-day operations to achieve optimal results.

Fit with Specific Strategic Goals

As described earlier, principles of Lean/Six Sigma have been successfully implemented in the manufacturing and healthcare industry. Implementation of its principles in the field of public health is a novel approach and will enable cities to develop and effective model to improve its operations, deliver care effectively and efficiently, and create positive health outcomes within its community. The Lean/Six Sigma methodology is a rigorous and disciplined approach to problem solving and culture change. It aligns with strategic health goals by providing a common language and weaves together the specific tools and deliverables used at each stage of the process as a common structured and organizational philosophy for continuous improvement.

-Mike Bonine

Never get between a Hockey Player and his Wife

During a recent family vacation to Lake Michigan in Holland, Michigan we ran into the local Meijer’s grocery store to pick up some items.  At the time I was wearing my Michigan State hockey tee-shirt, and on the way out of the store my wife was lagging a few steps behind me.  Another shopper was exiting the store at the same time and motioned for my wife to go ahead of him.  He stated, “I never want to get between a hockey player and his wife”.   So my wife went on ahead wondering who this hockey player was, while my son marveled at the influence a hockey player has on people, and the potential for a brawl to occur.

When I thought about this incident a few days later it occurred to me the never-ending stuff that can get between a company and its journey for continuous improvement.   In a perfect world, every undertaking has well-defined objectives, clear-cut operational guidelines, and exact metrics aligned strategically to measure success.  In reality, people charge forward without having their ducks in a row and barriers begin to surface that get in the way of your mission.

A PwC Mori Survey was conducted outlining barriers that prevent a successful mission or change.   The survey concluded that 90% of the barriers were people related, and lack of change management is a common barrier to achieve goals.   Some of the main barriers to change are:  (based on a percentage of 500 companies surveyed)

• Competing Resources
• Functional Boundaries
• Change Skills
• Management
• Unrealistic Timetables 

Every organization has impediments that get between the mission and overall success.  The one critical stumbling block I see most in companies deals more with management involvement.   Specifically, when you breakdown this component executive leadership is the number one factor for successful change, and I believe the most compelling obstacle to being successful.  Leadership has an incredible impact on change, and the effectiveness of an organization will rest on the top leadership team.

Albert Einstein and Coach John Wooden had a distinct impact on change and effectiveness in their respective fields.  Einstein and Wooden share a similar brilliance; openly, both mastered the complicated art of keeping it simple.  For Dr. Einstein, the complexities of nuclear fusion were summed up in the elegance of a simple equation: E=MC^2.  For Coach Wooden, 10 national championships, and 88 consecutive victories are summed up in the simplicity of an elegant formula: Conditioning + Fundamentals + Unity = Championship.  Simple as that.  Only not so simple.  The essential skill required to play hockey seems easy, right?  Skate, pass and shoot.  Unfortunately, there’s an incredible amount of agility, endurance, and expertise involved with those three simple categories of hockey skills.  When you look at Einstein, Wooden, or the ability to play hockey you must consider that an evolution is taking place. You must move past the equation and skills, delve deeper to understand the discipline, hard work, diligence, knowledge, and values that took place to achieve success.  The same is true for the executive leader.  If top leadership does not practice, understand, and delve deeper they will not be able to evolve, comprehend, and master the value, and methodology of continuous improvement on their organization.

Changing Existing Leadership Behaviors and Attitudes

In an organization successful change is hard and copying a leadership or a scientific formula does not guarantee a successful outcome.  There are a dozen continuous improvement roadmaps or formulas available with different variants.   Just selecting a roadmap and employing it will not lead to success.  I believe Einstein and Wooden were successful because of the fundamental concept of developing good habits in their mastery, consistency and philosophy.  On the surface the model may look easy, but beneath the surface leaders need to have a paradigm shift in their behaviors and attitudes toward change.  They must think differently about data, processes, people, and sustaining improvements.  Their ability to be successful will have a direct impact on their level of competency.

For an organization to be successful in their change endeavor, top leaders must develop good habits in:

• Mastering the rigors, discipline and principles of continuous improvement.   Those organizations that I have been with that had remarkable success in leading change had senior executives that understood, and participated as a Master Black Belt, Black Belt, and/or Lean Leader in prior roles within a company.   Chiefly, they made the decision to change existing behaviors and attitudes by rolling-up their sleeves and spending quality time to learn, practice, embed and blend the skills, and knowledge necessary to master the methodology of continuous improvement.  In essence, it became part of how they think, and operate; it is part of their DNA.

 

• Consistency.  A leader who consistently has the ability to stay the course.  They understand change is a journey, and does not happen overnight.  It is the ability to maintain a solid vision, to truly commit, demonstrate confidence, ask the right questions, and bring the best out of their employees on a consistent basis.

 

• Living a philosophy of continuous improvement.  Ultimately, helping and allowing others to achieve their own greatness by helping the organization to succeed.  This requires creating a foundation based on enthusiasm, and cooperation to constantly improve processes and people.  This is where the rubber meets the road.  If people cannot see your values in your behavior, then you will not succeed and you might as well be spinning your wheels because you will not be going anywhere.

Understanding and Improving our levels of Competency

We all want a department, an organization or personal success in our life.  But as John Wooden stated at the beginning of each season, “…for our success to become a reality you must first accept my concept of what success truly is.  True success shouldn’t be based on individual statistics or the percentage of victories, any more than success in life should be based on material possessions or a position of power and prestige.  Success must be based on how close you come to reaching your own particular level of competency.”  John Wooden was aware if his players focused too much on the outcome of the game by checking out the scoreboard, the game was lost.  What made the team successful was a mastery of the fundamentals; understand roles, teamwork, and the constant desire for each player to continually work at improving their skills and knowledge. 

 In an organization’s quest for continuous improvement, if we are always looking at the outcomes (the results), we will not be aware of those obstacles that get between us and success.  Top leadership will not be aware of their own developmental needs, understand the fundamentals, nor have the ability to master certain attitudes, understand roles, and achieve their own level of competency and teamwork.

I believe the best and most effective senior executives (CEO, Presidents, COO, and SVP) will begin to come from the ranks of those key individuals that have a blend of skills and knowledge of Lean and Six Sigma.  These individuals will have truly spent the quality time as a Master Black Belt, Black Belt and/or Lean Expert to master the levels of competency to achieve the desired business results, sustainability, and organizational / culture change.     

Improvement is everyone’s business.  It is a process-oriented way of thinking versus results-oriented thinking.  Continuous improvement must be ingrained in the minds of management and workers so that they often do not even realize that they are thinking about improvements.   As an organization you will know how to challenge, mentor, define, and promote the right values.  There will be less obstacles getting between you and success.  Like the hockey player, a healthy reputation or influence will develop, and events and people will not want to interfere with the organizational mission because the organization will have a strong foundation, good habits, unity, a purpose to succeed and a common determination to grow and learn.

-Mike Bonine

I recently finished reading the book “Deep Survival”, by Laurence Gonzales.  The following is a short narrative in the book called Danger Zones that resonated with me in many ways:

I boarded a United Airlines flight in Chicago and flew to the island of Kaua’i in the state of Hawaii.  Grabbing a ride from the airport, I checked into the Holiday Inn, and got into my swimming trunks.  I went down to Lydgate Beach wanting to wash off the airliner stink while body-surfing those big breakers I’d seen on final approach.   As I hit the sand in my flip-flops, I could see great lines of white foaming waves curling in toward shore from the deep blue water.  I couldn’t wait to get into the clear water.  I passed below Tower Number 5, heading towards the surf, and the lifeguard on duty there said hi.  I thought: people sure are friendly here.  I said hi and asked him how the swimming was.   “Well,” the life guard said, as if considering it for the first time, looking out to sea.  He came down from the tower and studied the sea.  “Okay,” he said at last, as if he’d decided something.  It was only then that I realized he’d been reading the waves, the lineup, and the break.  “See where that flat water is over there?  I’d say you can go in there and be okay.  But you get more than about ten yards off shore; the rip will carry you out and the current will take you around that swimming area, and bring you back in over here, and just beat you to death against those rocks. “Also, he stated not to go in any white water at all.  Wow, this guy knows what he’s talking about.  And: If he hadn’t been at his tower, I’d have jumped in and swum right out into those big, happy breakers.  It all looks so…inviting.  And I began thinking how easy it is to die.

Organizational Survival: Continuous Improvement Philosophy

As Laurence Gonzales described the above scenario I thought about the success rates and challenges of maneuvering the treacherous waters of implementing the Lean / Six Sigma methodology.  On the surface it looks inviting because of the positive results that can be achieved and the financial gains that can hit the bottom-line.   But too many times organizations “can’t wait to get in the water”, and then the “currents” of the present organization take hold and beat you to death.  These “currents” could represent the level of commitment, resistance to change in behaviors of individuals or a group, lack of strategic alignment, data collection issues or failure to have a proper orientation of the organizations current state, in order to achieve a future or ideal state.
Business change is difficult and should be based on the premise that each organization is unique.  Whether your company is launching a brand-new initiative, wants to “jump start” a tired Quality program, or is trying to expand a successful change process.   Like the lifeguard there are key individuals that have the mastery to facilitate and support the organization through these treacherous waters of deploying a philosophy of continuous improvement throughout the organization.

A scientist named Chuck Blay did extensive research on death by drowning in Hawaii.  He found that the rate of drowning was directly proportional to the number of tourists who came to the island.  To put it statistically, he stated that drowning is normal.  Looking across the horizon at companies that have implemented a continuous improvement philosophy, I too would classify as normal the number of companies that have failed to get a transformational change and sustainability of improvements.  In fact, I believe very few companies have transformed themselves if I define success as the state where continuous improvement is understood at all levels, embedded in the culture, and perpetuated as part of the DNA of the organization.

The toughest part of Change: Sustainability

One of the toughest areas of change is leadership.  Every organization has business problems, workflow constraints, customer needs and goals to embrace.  Often, businesses will identify a “change leader” (or a lifeguard) who has demonstrated mastery skills with Lean / Six Sigma deployment and implementation.  This individual usually has the blessing or authority of the senior leader to lead the change process.  The problem is this often results in a parallel organization and a disengaged leadership.  The fight is then for resources to continue the change process, and space to get the promised business impact.

The leadership is working from a division of labor model expecting the “change leader” to be the driving expert in implementing the methodology, technology, and solving problems.  In fact, department leaders are more than happy to embrace the “change leader”, expecting they will have very little commitment, if at all, and no accountability with the implementation.  As a “change leader”, they do not appreciate you coming back to them with more problems.  That is why they welcomed you in the first place, because you are expected to fix the problems.
To be successful within the change process, the role and responsibility of the “change leader “must be viewed differently through the organization.  The “change leader “role must be one who will facilitate and insist the leadership stay engaged, be accountable, and committed from the start.  It is important to be part of the senior leadership team, but make it clear to leadership that their role is critical to change.  This involves all leadership to:

1. A dedicated level of commitment to participate in the change process every day.
2. Have the clarity of understanding their role, and
3. The consistency of practicing what they learn, and drive positive behaviors.

To accomplish this requires teaching leadership the principles and concepts and then using pilots to illustrate the technology and its impact.  Leadership needs to understand at the start that we expect the pilot will not sustain.  It is their job to ask questions, and understand the whys.  In addition, to go after the broader systems problems and misalignments that get in the way of this new way of working, and begin to build an infrastructure that supports this new way of working and encourages employee involvement at all levels.

Summary
As much change as leadership expects at the operational level  is as much change that is going to have to take place at the leadership level (communication, voice of customer metrics, strategic planning, attention, personnel selection and development, philosophy, values, standards, discipline, and root cause problem solving).  Otherwise, the change will not be sustainable, and at best will only last as long as the champion is present.  Leadership will be required to work as an effective team, and the “change leader”, as part of this team must provide the knowledge, experience, insight, and mastery to ensure the organization does not get beaten to death against the rocks.

-Mike Bonine