A Guaranteed Method to Stop Team Wheel Spinning

I have sat through hundreds of unproductive meetings over my many work years and I would say that the great majority of team “wheel-spinning” could have been avoided using one simple tool: The Critical-to-Quality Tree which I now call the Critical-to-Success Tree because I think that name resonates better with most people.  I know I’m preaching to the choir in explaining this to my lean-six-sigma trained brethren but for those not familiar with the tool I can only say this; LEARN IT TODAY! It’s critical to any improvement project and should be the first tool you use before you go out and purchase any software or information system. 

In essence this is a tool used to take a "Big Goal" and convert it into sub-goals and the related metrics, which in turn can be converted into action items that will help you achieve your "Big Goal" . It’s on my top 5 must-use process improvement tool list.  

Take a look at my simplified example below:

We can say our "Big Goal" is to arrive at work on time but until we layout what that entails it is not going to happen.  In this example we take this rather simple goal of "getting to work on time" and work through the specific actions that will make that happen. For this goal many people could figure out the requirements and specifications by trial and error but using the tool eliminates that need.  The tool is completed from left to right with the left side showing a broad need or want and as you move to the right you get more and more specific about how to drive that goal. When complete it becomes clear that unless you are successful in meeting the specifications (far right)  you will not accomplish the broader goal (far left). Note that the specifications may require more detailed action items.

Consider a much more complex issue. Rather than getting to work on time consider a more complex problem that you think you can solve by installing a certain expensive software program or by completing a Lean project. Maybe you want to improve patient flow, reduce the cost of a surgical process, or increase MRI utilization.  Do you think you would understand the drivers and specifications of these complex processes without going through this exercise?

Lets use a complex “real life” problem that every Hospital is facing: How will the Hospital reduce Congestive Heart Failure 30 day readmissions? This is critical because starting in 2012 they will not be paid for additional services within 30 days of the first admission and related discharge.  Before you read further why don’t you grab a piece of paper and jot down what you believe are the drivers and specifications for such a project. If you get all of the drivers and specifications you see below I submit to your genius however my experience is that few individuals and almost no teams can layout the critical success factors without using this tool.  Now, with your “guess” by your side take a look at a recent Critical-to-Success diagram a team of ours is using for that specific goal.

While some may disagree on the exact format to complete this exercise and while there might be some minor quibbling about the exact drivers it is clear that the tool allows any team to bring much more focus to large and complex issues.  Before we did this exercise our team was trying to solve the problem in a semi-accurate (most people understood the basic issues) but random manner and we were not making very good progress. After allowing the team to struggle for a few meetings I intervened (with the facilitator), explaining the tool and its benefit. The facilitator was also frustrated with the team’s progress and being a very smart person he immediately gleaned the value of this tool and we worked on it together and then later with the team.  Once the team created this CTS diagram the dynamics within the team changed dramatically.  Armed with clear objectives the team members and the facilitator could spend their time accomplishing specific actions that will drive success. The team is making good progress and the wheel spinning has stopped.

 

CULTURE CHANGE - It's really about ice-cream versus chicken fingers & vegetables

In my last Blog I discussed the fact that a process improvement program should be geared towards creating an operational excellence culture.  Unfortunately many executives don’t fully grasp the fact that you can’t change culture, you instead, change behavior, which in turn changes culture.

As an organization you want to develop behaviors that promote the best-practice behaviors of top-performing organizations. Behaviors like trust, teamwork, reliance on data, open dialog, and transparency. When many organizations talk of starting an operational excellence program they talk about changing culture but they don’t spend enough time talking about changing behavior.  Many don’t make the connection.  Teaching your employees about Lean, Six Sigma, Balanced Scorecard and other improvement methodologies has value but unless the executive team exhibits correct behaviors and insists that all employees practice behaviors that align with the organization mission and vision, there will be no culture change. 

Many executives mistakenly think a dysfunctional culture creates bad behavior however when an organization is a poor performer you can always trace the root-cause back to poor behaviors, which in turn creates the dysfunctional culture. Too many executives think that culture change is achieved through training, and lofty “rah-rah” speeches and events.  Top performing executives understand that staff soon forget what is said at these canned events and training sessions, instead, they intently watch what executives do and model their own behavior accordingly.

Behavior alignment is probably the single most important concept that executives must understand if they intend to develop a continuous improvement culture.  Why?  Because you do not change culture directly, you can’t.  What you can do is influence and change behaviors and then, once the desired behaviors are reinforced (over and over again) you begin to change culture.  It’s not a “chicken and egg situation”, changing behavior always comes first.  Every effort must be made to ensure that executives and senior managers enforce behaviors that support the organizations goals and objectives and that they discourage behaviors that are contrary. 

Let’s take a classic parenting example.  It’s dinner time and your child really does not want to eat her chicken fingers and vegetables, she wants ice cream for dinner.  She can be quite insistent about the ice cream, crying, screaming, pouting, and refusing to eat.  For parents this behavior can illicit a wide range of emotions, from incredible sympathy (they don’t like to see their child upset) to anger and frustration.  The parent has really two basic choices, give in and let the child have ice cream or make it clear to the child that dinner is important and unless the child eats dinner and behaves appropriately there will be no ice cream.  If the parent chooses to allow ice cream before dinner what do you think happens at the next night’s dinner?  Of course, the child tests the rules again; after all, it worked once.  This testing goes on for many more nights until the child understands the exact rules of the house.  If the parent keeps allowing ice cream before dinner then that behavior becomes the norm and ingrained in the household culture. Soon there are no more tests by the child on this matter, no more tantrums; ice cream is eaten before dinner every night.  The parent did not develop the household culture directly, they established what the child perceives as acceptable behavior and in turn it becomes a cultural norm. Why would a parent allow such behavior? It’s pretty obvious that most nutritionists would cringe at such a choice, however the parent is making a trade off, they have determined that a little bit of ice cream and potentially poor eating habits are less of a concern than an upset child.  Humans are the masters of justification and CEO’s are no different.    

If an organization has dysfunctional management, a top-down command and control structure, a lack of flexibility, and overall poor financial performance it is very likely that this organization encourages or tolerates poor behavior which has created a poor performance culture.  Poor performance drives the need to change culture and this can only be accomplished by encouraging desirable behavior, thus as a first step the organization must understand what type of behavior it desires.  Desired behavior is driven by the organizational strategy and from that strategy the organization’s objectives and goals. 

Remember the parent with the ice cream loving child?  You are now that parent.  The children are used to ice cream - They want their way and they need an authority figure (CEO/Parent) to reconfirm that you agree.  Like any parent, you can avoid conflict and all the pouting and hurt feelings that go with refusing the ‘wants’ of your child or you can insist that both parties focus on the proper corporate goal and related behavior.  If you choose the former you have just violated your behavior alignment plan and even worse, you have encouraged the bad behavior and in turn reinforced the current culture model.  

Don’t think this can happen to you?  Let’s take a typical problem - Two VP’s are not getting along on a large project. Their issues involve typical bad behaviors involving rivalry between their “siloed” organizations and mind-sets that are far from flexible; they have a meeting with the CEO to discuss their issues. The CEO hears them out but defers any resolution; after the meeting the following occurs:

Scenario One

The CEO thinks through the issue this way: George has been here for 20 years and is a valued employee and the same goes for Susan; both have bailed the company out of tough situations.  I don’t think this battle is worth fighting I need to get them to move on to some less controversial issue and let them run their departments as they see fit.

The CEO arranges separate meetings with George and Susan and tells both of them this: “Try to get along and work out your differences, I don’t think you should make a big deal of this, just concentrate on improving your areas and do the best you can”

Scenario Two

The CEO realizes that behavior modification is needed. The CEO calls a joint meeting with George and Susan:  “George, Susan, I really value your contributions to this organization and I realize you have strong opinions but you need to stop focusing on what is comfortable for you and start thinking about what is best for the organization.  I want you to get back to the team and use others to help you see this issue from a different perspective, a perspective that subjugates your needs to the organizations needs.  I want this issue resolved by the end of next week.  You are both highly competent and need to use the team and facilitator to help you determine the best solution.  Please set up a meeting with me next Friday, I expect that you will not let me down.” 

In this second (desired) scenario the CEO stuck to her behavior alignment plan – Develop cross-departmental cooperation (teamwork).  Next, she strongly discouraged the “old” and bad behavior and made it clear the importance of adopting the “good” behavior.  At the same time she acknowledged that the she valued both employees but was not going to value the “old” behavior.  When George and Susan return next week with a solution the “good” behavior will be reinforced with high praise.  After this pattern is repeated with others it will not take long before it becomes understood that the COO values teamwork and we all better learn how to cooperate and work together.   Once the behavior is repeated enough times the culture will begin to change; from a siloed, self-serving culture to a teamwork culture.   That is the power of behavior alignment. 

Executives need to take note.  If you fail to be vigilant and constantly work at behavior alignment you will not be able to achieve your goal of creating a culture of continuous improvement but even worse, you will be perceived as a poor leader because you promised change but did not deliver. 

A Process Improvement Program by any other name would smell as sweet

There are a multitude of names given to process improvement programs. Some organizations like to use: Six Sigma, some use Lean, Lean Six Sigma, Operational Excellence, Organizational Effectiveness, Process Improvement, Process Innovation, and Process Transformation to name a few.   Some organizations use lean six sigma but don’t call their experts Black Belts or Senseis; they may refer to them as “XYZ Process Expert Level 1”

While many organizations spend an inordinate amount time thinking of the best name of their programs or their experts, the names have little meaning when it comes to developing a good program that delivers results. That said, my personal prejudice is to use a program name that is more generic and does not reflect a specific methodology. For example you can see that my blog involves the term operational excellence. The problem with using program names such as “Lean” is that people immediately assume that all answers lie in that particular tool set and it does not take long to shoot holes in the methodology if it is applied like peanut butter to every problem.

Back to the “name does not matter” idea.  In order to deploy a solid process improvement program you must concentrate on changing behavior in order to create a desired culture.  You don’t change culture; you change behavior (I’ll cover this in more detail in another blog).  Most organizations don’t develop a culture-centric program but instead they develop a project-centric program. Try this experiment: Ask a CEO that has a process improvement program in place to tell you what the program does.  Most of the time they will tell you “ We have had great results, we have cost reduction projects, patient satisfaction projects….” and on and on about projects and project results.  Now ask that same question to the CEO of an organization that is a top performer; the answer you get will be much different.  They will say something like this “ Our program is helping us develop a culture of excellence so we can meet the challenge of the next decade and provide our employees with greater opportunities.” Do you get the difference?  Of course the top performer CEO has a program that is running projects but they understand WHY they are running projects. 

Now back to the “name issue”.  When an organization tells employees they are going to be a Lean Hospital or a Six Sigma Hospital they are missing the point.  Lean, Six Sigma, Balanced Scorecards, and Theory of Constraints are methodologies and tools that help change behaviors but they are not by themselves the only drivers of culture change. These methodologies contain powerful tools and methods that can help an organization solve problems, improve processes, remove constraints, and create accountability but none of the by themselves are the “silver bullet” that creates a culture of continuous improvement. 

Team Diversity makes for better project outcomes

Have you ever wondered how a team works in spite of the diverse personalities?   We have all been in a team meeting where we find ourselves screaming (hopefully only on the inside) because of our frustration with a team member’s inability to comprehend a concept or with a team members disjointed ramblings off topic.  In my early years these situations truly bothered me and created a lot frustration but as I facilitated more and more meetings I finally realized that everyone is not like me!  And they don’t think like me either!

Diversity of personalities and thinking styles are critical to a great team and helps avoid group-think. As facilitators we need to embrace the differences and use those differences to an advantage, I like to categorize my team members into 5 personality types and I always try to get 4 out of the 5 types, read on and you can guess which type I try to avoid:

The “Thinker”: This is the person who does not talk much and is a good listener; they often come up with great solutions based on the various inputs from other team members. They can keep you out of trouble because they tend to be balanced in their approach and while they believe in stretch goals they also keep the tam from "over reaching". Always try to get a “thinker” on your team; they often have the respect of other team members and thus help you build credibility.

The “Emotion Train”: This person brings heavy emotion to the group and if left unchecked, they can be become a speeding freight train, destroying everything in their path.  However, if controlled, they can bring great value to the team.  While they often take “side trips”, can sometimes get “personal”, and often start off somewhat negative, they often provide a vivid unadulterated recollection of past mistakes and cultural norms.  If you listen closely you will learn about barriers to change, past failures, and also get a flavor for where certain key mangers stand on project efforts.  For logical folks like me it is sometimes frustrating to listen to “emotion trains” however they provide great information. They are a good personality type to have on the team but you have to make sure they do not become a distraction (AKA an out of control freight train), I often enlist the next personality type to help me in that endeavor.

The “Politician”:  This is the person who does not contribute a great deal of new ideas; instead they frequently repeat with others have said making sure that they understand what that person needs and where they are heading.  They are hesitant to offend anyone so they rarely come up with anything controversial or “out of the box” however they help bring a certain sense of clarity to the group and can often be helpful in smoothing any ruffled feathers when someone takes offense at a comment. Together with the “emotion train” personality they help you understand the culture of the organization. They are good communicators so make sure you enlist them to help garner support for team efforts.

The “Passive Resistor” This person is the toughest to deal with when you are a facilitator because they are impossible spot quickly.  They tend to agree with the direction of the team and avoid group disagreement; therefore you don’t always determine their nature until several meetings have gone by. As we all know once the “passive aggressive” member is out of the meeting they either ignore the action items or sabotage team efforts at improvement.  These are highly experienced “stone-wallers” so you rarely win by trying to deal with them head-on. They are essentially insecure so you may be able to uncover their insecurities and build their confidence but unfortunately this may take a long time. You need to be persistent in getting them onboard usually by providing them with minor tasks that you make seem very important but if that fails, you go to plan B; minimize their team involvement.

The “Workhorse”: This person is semi-interested in the dialog and creativity but their real talent lies in doing things.  Give them a task and they will get it done.  Because they don’t tend to quickly comprehend the bigger picture you need to be careful and patient in order to get them onboard with ideas and concepts but once they buy-in they will carry a lot of the workload and require no special “stroking” as they tend to have low ego levels however, they very much appreciate recognition within the group.

Sometimes dealing with many personalities can be frustrating however the frustration is worth every “tums” you chew because you always end up with better results when you work with a diverse team.

Operational Excellence for Hospitals: May the "Force" be with you

Operational Excellence for Hospitals: May the "Force" be with you: "Are you a fan of star wars? Ever think that you might be living the movie? The other day I thought about how life as a process improve..."

Operational Excellence for Hospitals: Metrics are dangerous - Be careful what you wish f...

Operational Excellence for Hospitals: Metrics are dangerous - Be careful what you wish f...: "Is there a manger out there who would say they operate without metrics? NOT. After all everyone knows that what gets measured ge..."

Metrics are dangerous - Be careful what you wish for!

Is there a manger out there who would say they operate without metrics?  NOT. 

After all everyone knows that what gets measured gets done, right?  Here is the problem, most managers either use the wrong metrics or only use one dimensional metrics to drive behavior. 

Let’s take a recent example I have seen first hand.  A Materials Manager is being measured on order fulfillment rate.  They have a goal of filling orders 99% of the time; they currently are at 99.4% fulfillment. Is this a good thing?  Does this make the organization more profitable or efficient? 

How about if I told you that over 4,000 individual orders a month are processed. How about if I told you that the number of orders being processed is going up every year but the volume of supplies is relatively flat. How about if I told you that our cost of expediting shipping has risen by 30%?

Here is another prevalent example common in many Hospitals. 

The Hospital employees a physician liaison to build bridges with community MD’s and to produce more referrals. The metric for this person is the number of visits to community MD’s.  Do you think monitoring such a metric will drive the desired results?   Can you come up with some other metrics that might be useful?  Does quantity over quality ring a bell? With this one metric how long will it take you to determine the effectiveness of the program?

I think you get the picture.  Be careful what you measure because it may just get done

Captain Kirk of Star Trek fame is a good role model

For those of you who are Star Trek fans you already know the main characters of the Star Trek series but for those of you who are not let me elaborate (you “Trekies” can skip to the next paragraph).  Star Trek is about the adventures of the star ship U.S.S. Enterprise and their diverse crew who are involved in space exploration.  These future space travelers zoom through the Galaxy at light speed seeking out new life and exploring new worlds. There are three main characters on the Enterprise: Captain Kirk, Commander Spock, and Dr. “Bones” McCoy.  If you watch the series you quickly realize how different these three good friends and crew mates are.  Spock is a Vulcan, born of an alien race that believes in pure logic without emotion.  Dr. McCoy (AKA Bones) is the star ship’s medical doctor and is a study in pure human emotion.  Their leader, Captain Kirk is a man who seems to blend the two other personalities.  He is fairly logical but is often willing to put logic aside when his “gut” tells him to do otherwise. 

These three very good friends face a lot of scary moments together during their many exploratory missions.  When faced with a dilemma where a crucial decision needs to be made Kirk will ask for advice and inevitably Spock gives advice based on logic and “Bones” gives advice based on emotion. As expected Spock and “Bones” often disagree on a solution and there are often many arguments between the two, many of these  involve “Bones” emotionally hurling various insults at Spock (good naturedly of course).  After listening to his crewmates Kirk sometimes chooses the logical path and sometimes the emotional path but more often, he takes a middle ground because he sees the value of utilizing both logic and emotion in his decision-making.  As Operational Excellence leaders we frequently venture into uncharted territory - new projects where we often face hostile “alien” team members.  I have seen all kinds of facilitators from the emotional to the purely logical and everything in between however I think the most effective OE leaders have characteristics similar to Captain Kirk.  They keep their cool even under the most extreme pressure and while they never lose sight of the end game and the need for logic they understand the emotional side of human nature and don’t ignore its power. During the course of a project they are willing to take a few detours in order to satisfy the emotional needs of those hostile “aliens” who tend to mellow as their emotional fervor subsides. At the same time, good OE leaders don’t let emotions get out of hand; they deftly keep the team away from any emotional “death spiral”.  Every team has its characters, the Spocks (usually my engineer or research friends), the “Bones” characters (usually my nursing or marketing friends), and all the in-betweens.  A good leader (and Captain Kirk is one of the best) must carefully utilize the strength of each personality and talent without allowing one to overwhelm the other.  OE leaders need to be an orchestra conductor. One instrument, by itself can make great music, but when a conductor harnesses the power and brings balance to the many instruments of an orchestra the positive effects of the music are multiplied 10 fold.   

For Captain Kirk failure is never an option, the lives of his crew often depend on his decision-making. The crew of the Enterprise is a diverse bunch with many faults but directed by Captain Kirk, they work together and become a powerful and unbeatable force.  At the start of the Star Trek shows Kirk is heard describing their mission:  Space... the Final Frontier. These are the voyages of the starship Enterprise. Its continuing mission: to explore strange new worlds, to seek out new life and new civilizations, to boldly go where no one has gone before.  Doesn’t that sound a lot like your job as an Operational Excellence Leader? 

Quick process improvement hits can have a BIG impact!

When you start to work on a project don’t forget to look for quick hits that may make an impact without the need for any detailed process improvement methodology.  For example: I’m working on a fairly significant redesign of how our Periop area operates and as we delved into the current process and opportunities we uncovered many small changes that could help the process immediately.  One of those changes involved standardizing how we review the Operating Room (OR) and Ambulatory Surgery Unit (ASU) surgical schedules.  The daily routine is supposed to involve a daily review of the next day’s surgical schedule.  In our situation the two areas are 1700 feet apart yet they both share some limited quantities of very expensive equipment and surgical sets. The daily schedule review is critical because there may be conflicts with surgical set usage, the schedulers may have under or overestimated surgery times, or the Surgeon may have not sent over critical information regarding supplies and sets needed (we often use loaner sets from our vendors).  It is also important that the Surgical Nurse Managers and our Sterile Process Supervisor talk about the schedule together as each has a specialized expertise that is needed.  A typical problem might be:  A surgery scheduled in ASU at 8AM that is using a scope that must be sterilized and sent to the OR for a surgery at 9:30AM; this is a problem because it will take at least 2 hours for the scope to be processed therefore an unrealistic schedule conflict has been created.  

While each Surgical Nurse Manager always reviewed the schedule daily, they did not do it at a consistent time, they did not always do it together, and they did not include Sterile Process in the review (although they occasionally called Sterile Process regarding specific problems assuming they remembered and/or did not get distracted).  We determined that the three key players must meet every day at 11:30AM to review the schedules together and then note issues on a check list to make sure all problems were addressed before the next day’s surgeries.  The results of this simple change have been dramatic: We have eliminated “emergency” scrambles regarding needed surgical sets or equipment (these use to happen at least 3 out of 5 days); the surgeons are noticing that the coordination is cutting their surgical times, and the three departments are developing a camaraderie that was lacking.   There is still a lot of project work needed for us to gain significant efficiency gains but these small victories give a boost and provide greater credibility to the larger project efforts. 

A Process Improvement Lesson from the Libyan Rebels

The recent events in Libya remind me very much about how highly charged emotions always trump logic. At the beginning of the rebellion the Libyan rebels were flush with excitement and had an over-confident sense of invincibility.  I remember watching news clips and listening to the radio about how the rebels refused to be trained in the basics of marching and military tactics by the professional and experienced military pro-rebel leaders. Instead they were screaming “Just give me a weapon, I need to go fight, this training is a waste of time!”  Most grabbed weapons they had never used before and rushed off to the “front”.  It reminds me of the situation we face within process improvement as we try to teach an inexperienced project team to use a DMAIC methodology and the proper process improvement tools in order to solve complex problems.  Many of our trainees are frustrated by the methodology and the perceived slow pace.  They fail to see the value in defining the problem and working out potential solutions on paper and within a small pilot before implementing the improvements throughout the organization.  

Until the recent intervention by NATO the rebels faced almost certain defeat at the hands of the experienced Qaddafi forces. They were being slaughtered by the hundreds and thousands; they were completely unprepared to face a disciplined and well supplied army.  Before reality struck the rebels perceived the world through a very narrow lens – “We had no freedom now we are free so we must be powerful”. There was no thought to past history in their own country or in nearby countries were dozens of rebellions are crushed every year. Organizations, like the rebels, often look at success through a narrow lens that only reflects their small world: “Our costs are down 5% from last year, gosh we are awful smart and successful”; never mind that our main competitor’s costs are down by 15%.    

Many teams we coach are quick to forget the many years they have spun their wheels on the same problem over and over again. Past failures are often marginalized and excused away, blaming any problems and failures on specific individuals or on a “lack of management commitment”. 

I doubt there was even one experienced rebel military leader in Libya who thought the rebel’s impetuous actions had any hope of success and yet, they also knew that trying to stop their illogical initial actions was futile.  A good process improvement leader needs to strike a delicate balance; helping a team exhaust highly charged emotions while also using the right tools and methodology to help them see reality and to open their eyes to a much broader perspective. Unlike the situation in Libya, no lives are in danger (although sometimes it is a close call), but the revelation that the rebels experienced a few weeks ago when they were quickly defeated by Qaddafi’s forces has some relationship.  As process improvement facilitators we must present our team with many unpleasant but irrefutable facts so they are shocked back to reality; sometimes it is the only way that logic can gain a foothold and we can start to bring ego and unrealistic expectations under control. It’s too early to see if the reality of the recent conflicts will changed the way the Libyan rebels approach their future actions but one thing is certain, if they don’t learn to keep emotions in check and apply sound strategy and tactics they will not succeed.  The same goes for the many healthcare organizations that choose to mimic the “Libyan rebel methodology” which can be summed up as a fire, aim, hope methodology.