Structure and Teams That Promote a Culture of Continual Improvement

"Start as soon as possible to construct with deliberate speed an organization to guide continual improvement of quality." - W. Edwards Deming

Lean success is sustained only when leaders and managers develop the environment, structures and aligned incentives to foster an educated and trained workforce that is empowered to work horizontally along the path of workflow. This is the key to obtaining the hundreds of small, granular process improvements done at the level of the work that the employees truly own. A Lean culture is successful when workers are informed by metrics of work variation and empowered to make change, in concert with their leader, using the scientific method, e.g., data-driven PDCA. Transformation to this culture of work and the structures designed to foster this manner of continuous process improvement by the workers are the responsibility of the leader. To begin a Lean journey without thinking through this structural element is toying with failure. Don't do it.

In a true Lean management culture you don't have to have all the answers anymore. Your people do. The answers you provide are the organizational structure, reporting relationships, accountability, pace, recognition and reward and incentive to work in the new order. This approach to work allows you to tap the creativity from the workforce, continuously.

Without a structure though there will be potential chaos with so many anxious to use their new found empowerment. Its one thing to tell someone they are empowered but quite something else to provide structure to ensure they behave in an empowered manner, respecting the existing order. This empowerment may range from serving as a leader of a defined work team, representing team members of customer-supplier meeting, or serving as a team member who consistently signals defective work and its causes through workplace whiteboards.

Toyota's production management system, the basis of Lean, is structured to thoroughly eliminate waste in pursuit of maximum cost reductions. That structure is defined by leadership and underscores the behavioral expectations or culture. However, there is no direct translation and the structure and principles successful for Toyotas culture must be adapted from manufacturing to our healthcare environments.

The Transformation Process

The process of transforming to a structured culture of continuous quality improvement looks like the figure below in Toyota. It begins with training of top management, agreement and definition of the quality mission and goals, team leader training in process improvement, identification of quality targets, then learning by doing at the 'shop floor' level in a model line area. In this scheme it is the Team Leader who is responsible for immediate patch fixes on the shop floor and more sustained process redesign through A-3 based PDCA change. The team member, who is on the automated line, is responsible for calling attention to the defects encountered or stopping the line so they can be fixed.

In healthcare, we don't have a shop floor or an automated model line producing cars. But we do have analogous opportunities for highly educated and trained workers themselves, not just Team Leaders, to become engaged in the process improvement at the level of the work, wherever that may be-- at the bedside, the clinic, the laboratory bench, the radiology suite, the emergency room, the ICU, the OR, the kitchen, etc.

The figure below depicts our HFPS model for Cultural Transformation in healthcare where first the leaders train as a cohesive group, then the team members are trained and empowered to work together in a defined structure before 'learning by doing'. We find it is far more effective to train the team rather than the individual. We also include the requirement for workplace metrics of performance expectation and variability that Team Leaders and Team Members own. This serves to frame the ongoing identification of quality target goals for teams to achieve.

Defining Reporting Relationships for Accountability

In the Henry Ford Production System, we have adapted to our healthcare environment the best of several structures (see figure below): 1) Toyota's line-level organizational structure for quality improvement using Group Leaders, Team Leaders and their respective Team Members aligned with 'work stations'; 2) Team Members empowered to represent their team in Customer-Supplier meetings in the interface as work is passed across work stations, units, departments and hospitals; and 3) Process improvements lead not by the Team Leader as in Toyota but by the empowered healthcare Team Members themselves. This requires leaders to adopt the Deming-style of management rather than merely applying the principles and use the tools of Toyota's efficient production system in focused projects.

That organizational structure is depicted in the cartoon below for continuous improvement linking numerous multidisciplinary work stations and teams at the level of the worker. It is expanded for the work designated "Initial Patient Evaluation" into further sequential Teams along that path of workflow contributing to "Initial Evaluation". If there is no designated Team Leaders, for these 'work stations', make sure that there are.

Defining Work Cells and Teams

The role of leaders is to talk with those who actually do the work and diagram just what these 'work stations' are and what they do. Our definition of a 'work station' in healthcare is described in the figure below. You are now creating a Work Process Flow Map, understanding what is done so you can create reporting structure for change. The next steps will allow you to understand what is done that adds value, doesn't add value but is required or what is done that is of no value and can be changed.

The structure should define work as it is done or contributed to or passed to numerous contributors. How do you get to this point? Here's a suggestion. Tape a long piece of butcher paper to the wall and begin diagramming the flow of your product or service to follow the patient, or the specimen or the invoice, etc, sequentially, until your are finished with all you can do. That is your work station. Align and connect these work stations horizontally and identify team leaders and members for each work station. You may identify inefficiencies of work looping back to the same work station or forking to two different work stations for no good reason. These are opportunities for work flow redesign.

The identification of a Team Leader, if none already exists, may be accomplished in a number of ways, as listed in the next figure. The option to bypass a non-effective Lean team leader with the appointment of a co-leader should be noted as a dysfunctional team is a significant barrier and the role of the team leader is often key to success. For areas with multiple shifts, it is important to have a team leader for the work station on each shift so that the input and voice of all workers can be channeled for continuous improvements.

Customer-Supplier Meetings

In this management model, employee empowerment includes the ability to call for a customer-supplier meeting as a means of actively increasing communication and initiating the process for implementing change for improvement. Because of the complicated nature of serial, parallel and, at times, disconnected processes contributed by numerous highly trained individuals in healthcare, it is often difficult for employees to comprehend the magnitude and the downstream effects of their own work, especially if not done to a standard specification, if that even exists. To compound this problem, we have inherited a culture of change of top-down directives that address crisis issues. Customer-supplier meetings involving empowered teams are designed to allow workers to gain a detailed sense of the work product or service that each section requires to function more efficiently as that product or service is passed from one work station to the next. This fosters management in a horizontal fashion along the path of workflow. Discussions involve highly specified requirements to aid in the direct hand-offs between customers and suppliers so that the main types of waste in processes can be eliminated. Barriers between work stations and professional groups can be more readily eliminated when people recognize that issues between work stations are universal and fixable and the typical finger-pointing 'blame-game' can be stopped now that they are empowered to remedy the situation. Eventually, suppliers understand and accept the demands of their internal customers and begin responding by changing processes to meet customer requirements. With this new understanding of team, eventually the culture begins to change.

"Your methods are formed by what you are trying to do; they do not determine your purpose. To my mind it is starting wrong to put methods ahead of purpose." -Henry Ford

These structures described above are needed to prepare people to work together, to form healthy work relationships from a vantage point of understanding other's requirements, to communicate freely and effectively in a blame-free environment and to be fully engaged daily in a common goal of excellence. This, in turn, can foster workers' sense of pride and accomplishment in contributing, no matter how small, to the success of the enterprise. Did someone say Gallup scores?

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