John Toussaint’s Monthly Reflections – What’s Next?

I was talking to a colleague this week who is the lean transformation leader at a large multispecialty physician group in California. He has a great deal of lean transformation experience. He asked me, “So what’s next? We have taken the transformation journey as outlined by Catalysis and we want to know what’s next.” It was clear that they had done a great job on many of the key areas of transformation, including setting behavioral expectations, training leaders as coaches, developing model cells, deploying strategy, etc. but there were some gaps in learning. Let us review the transformation framework he was talking about.

At Catalysis we have identified five swim lanes of change guiding the organizational excellence journey. The first swim lane is the board. The board must be supportive. In addition, they need to practice the principles of organizational excellence to understand the work and the culture change going on within the organization. It is the executive teams’ job to make sure the board is exposed and that there is a plan for them to be engaged in the work.

The second swim lane is the executive team. Executives must have a coach and be willing to be coached. They need to learn how to go to the gemba and ask open-ended questions. They need to learn leader standard work. They need to practice A3 thinking. The personal journey may be the hardest part of the change. For this work executives create a personal development plan using a personal A3. This is as opposed to a problem solving A3. Self-reflection is the most powerful way to change ourselves. Understanding the background and current state of our leadership style and then analyzing why we act the way we do leads us to the right side of the A3. Answering these two questions can help guide experiments leaders can try. What did I do this week that unleashed the creativity of my team? And what did I do that shut them down?

The executives, as a team, are also responsible for developing True North, Key Behavioral Indicators, Strategy Development, Strategy Deployment, and Visual Management. These systems and behaviors are created over time and require a knowledgeable facilitator.

The third swim lane is the performance improvement (PI) team. The PI team members should be coaching both up and down. Yes, coaching rather than doing is the core function of the PI team. When I was CEO, we hired facilitators to run kaizen events and value streams. These tools are important, but the PI team needs to be teaching managers and front-line workers the tools, not doing the work themselves. Capability will not be left behind if the PI team members do all the work.

The fourth swim lane is the model cell. There are two types of model cells. Those that emerge from breakthrough value stream improvement led by the PI team and those that emerge from a different process led by a Research and Development (R&D) team that we describe as New Care Model Development (NCMD). The measure of success for model cells designed using breakthrough value stream improvement is 50-100% improvement from the baseline performance. Front line staff are deeply involved in the value stream work that leads to the new design and eventually the execution of the model cell.

If breakthrough value stream improvement is not achieving the level of improvement required, it may be that the existing process has reached its limit of performance, which means the process should be obsoleted and a new way of delivering care created. This requires a different system. This system is the development value stream, better known as R&D. Most health systems do not have an R&D function. Today we need to obsolete many of the processes in health care delivery that do not work and replace them with patient-centered care that delivers greater value. That will not happen unless we build a system to deeply understand customers’ needs, develop radical new concepts from this knowledge, and rapidly test the concepts in patient environments.

In both breakthrough value stream improvement and NCMD an executive sponsor is required. Leaders must be patient. The work may take six-nine months before the new standard work can be spread to other areas.

The final swim lane is the support functions. HR, IT and finance leaders can make or break the transformation. For example, all three play a crucial role in model cell development. Staff jobs change, and that is real work for HR because new roles may not fit neatly into previous job titles. IT must support new processes by turning on different EHR functions and finance needs to look at the new design results systemically rather than by line item.

Back to my discussion with my colleague. With the above transformation journey guidepost in mind, we found that very little work had been done at the level of the board swim lane. Some board members were deeply engaged but some were not engaged at all. We also found there may need to be consideration for creating a development value stream and obsolete some existing care processes that were functioning poorly. Finally, he felt it was time for his leaders to learn from other leaders by joining executive forums and interacting with leaders on the same journey.

All organizations have gaps on the transformation journey. What are the gaps at your organization? I am keen to know what’s next for you.


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