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TOP 10 TOYOTA KATA LESSONS

There are my top 10 lessons learned from practicing the Toyota Kata approach in a healthcare setting.

TOP 10 TOYOTA KATA LESSONS

  1. 1. MY TOP 10 LESSONS LEARNED FROM PRACTICING THE TOYOTA KATA APPROACH By Michael Lombard March 2014
  2. 2. Background… The topic here is lessons I've learned (so far) from my grassroots effort to infuse the Toyota Kata methodology into the culture of an acute care hospital in the Dallas-Ft. Worth metroplex. When we began testing the Toyota Kata approach we had no experience with or knowledge of it at all, outside of having read the book a few times. We had no budget to bring in experts or send ourselves off for formal training. Context at a Glance • • • • Acute care hospital in the Dallas-Ft. Worth metroplex No prior Toyota Kata experience or expertise No budget for consultants or off-site training Strong leadership support for continuous improvement But, thankfully, we did have senior leader support to try something different; they were ready to invest significant effort in building a sustainable culture of continuous improvement at our hospital.
  3. 3. How we started… We didn't know where the path would take us, but we took a step forward anyway. First, we selected an Advance Team from different departments and levels of the organization. Then, we did a tiny bit of home-grown training and quickly got to work practicing the Kata in the real-world. Advance Team Selected Initial Training Practice & Learning Sharing Lessons Learned June-July 2013 August-Sept 2013 Sept 2013-Feb 2014 (& Beyond) March 2014 Now, after about six months of real-world application including several hundred coaching cycles, I have some lessons learned that I'd like to share...
  4. 4. #10 A PDSA cycle is not what I thought it was… I always thought a PDSA cycle was when you had identified a countermeasure to a problem and wanted to test it. Well, yes, that is one type of PDSA cycle, but there's more than one kind. Sometimes, our PDSA cycle consists of nothing more than a quick "go & see" to confirm or deny a hypothesis, without changing or implementing anything at all. I've come to see a PDSA cycle as simply the act of taking a step forward with the intent of learning something in the pursuit of improvement. 3 Examples of PDSA Cycles 1. Go and See: Direct observation and data collection, without changing anything, to learn more about a process or situation. 2. Exploratory Experiment: Introducing a change in a process to see, via direct observation, how the process reacts. 3. Testing a Hypothesis: Introducing a change, ideally in only a single factor, together with a prediction of what you expect to happen.
  5. 5. #9 Cues, routines, and rewards matter… Since organizations have many built-in impediments to organic continuous improvement (annual performance reviews, TPS reports, etc.), we must actively pursue continuous improvement through organizational habitbuilding. In The Power of Habit, Charles Duhigg explains that for new habits to form, we must have a habit-building loop in place consisting of a cue, routine, and reward.
  6. 6. Cues • Formal coaching cycles • Visual signals (e.g. 5 Questions pocket card) Toyota Kata Habit-Building Loop The Toyota Kata approach provides all 3 elements of habit-building in abundance Intrinsic Rewards Routines • Learning • Solving problems • Attaining Kata mastery • Improvement Kata • Coaching Kata
  7. 7. #8 Track the metrics of habit-building… A target condition should always be measureable. However, in the early stages of Kata adoption the focus is more on building habits than producing huge process improvements with eye-catching ROI calculations. Therefore, it's advisable to also have a way to measure progress in terms of habit-building. For example, we can track the # of Kata "practitioners", # of Kata coaches, # of PDSA cycles performed, etc. I'll admit that this is a highly imperfect set of habit-building metrics, so I'm hoping as a community we can come up with something better. One option might be to measure what level of skill our people have attained using a standardized rubric, as suggested in some of Mike Rother's online material.
  8. 8. # Improvement Kata Practitioners by Month 45 40 35 30 25 20 15 10 5 0 # Coaching Kata Practitioners by Month 14 12 10 8 6 4 2 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 0 Jul-13 # PDSA Practitioners Added Aug-13 Sep-13 # PDSA Coaches Added Cumulative Total # of PDSA Practitioners # PDSA Cycles Performed by Month Oct-13 Nov-13 Dec-13 Jan-14 Cumulative Total # of PDSA Coaches # Departments Utilizing the Kata by Month 250 25 200 20 150 15 100 10 50 5 0 0 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 # PDSA Cycles Performed # Departments Added Cumulative Total # of PDSA Cycles Performed Cumulative Total # of Departments Using PDSA Jan-14
  9. 9. #7 Clinicians and other front-line staff tend to like the Kata approach. Target Condition I think this is because it allows them the freedom to take one bite of the apple at a time. They are free to try a small change or just go get more information, all in the pursuit of learning and iteration. This reduces the fear of failure and the stress of trying to do too much all at once. It's quite liberating to be able to see the top of the staircase and take a single step at a time. Current Condition
  10. 10. #6 It works on big projects too. We've seen great success in using the four steps of the Improvement Kata as a roadmap for fairly large improvement projects; the 4 routines of the Improvement Kata serve as project phases, as shown below… We utilized a Steering Team to build consensus for a vision statement, KPIs, 1-2 year goals, etc. The cross-departmental team developed the future-state map and built consensus with the Steering Team to obtain approval. IK STEP 1: IK STEP 2: IK STEP 3: IK STEP 4: • Understand the Direction • Sept-Oct 2013 • Grasp the Current Condition • Oct –Dec 2013 • Establish the Next Target Condition • Dec-Jan 2014 • PDSA Toward the Target Condition • Jan-April 2014 We utilized a cross-departmental team to analyze the current-state via a series of halfday “work-out” sessions. We broke up the future-state map into 6 elements that were assigned to 6 learners who were guided by 1 coach.
  11. 11. The Improvement Kata can be utilized for any type of improvement effort, including big, formal projects. The four routines of the IK provide a nice 4-phase framework upon which we can plug & play whatever project we need. IK STEP 1: IK STEP 2: IK STEP 3: IK STEP 4: • Understand the Direction • Grasp the Current Condition • Establish the Next Target Condition • PDSA Toward the Target Condition
  12. 12. #5 Target Conditions ≠ Numerical Targets ≠ List of Countermeasures This was one of the hardest things for me to grasp as a coach. I almost immediately understood that a target condition is not the same as setting a numerical target or goal; yes, we actually have to describe the future mode of operation that will produce the results we seek. This I understood. What I didn't understand was that describing the future mode of operation does not require us to know exactly how we will achieve it. In other words, we don't need a specific list of countermeasures to be able to describe the target condition. In fact, it's better not to lock ourselves into preconceived notions of what solutions are needed before we've began testing via PDSA.
  13. 13. Here’s a comparison of numerical targets vs. countermeasures vs. target conditions using a healthcare example… Scenario Numerical Target We want to improve patient safety 10% reduction in medication errors by Q2 2014 Countermeasures • Implement CareFusion barcode scanning • Switch to new armbands that don’t wash out • Re-train nurses We often think that setting measurable stretch targets will motivate our people to fix the problem, but that’s based on an assumption that a lack of accountability is the root cause of the issue. Where’s the evidence for that? Target Condition A future-state of a highly reliable armband scanning process powered by automation that will reduce the risk of missed armband scans to reduce medication errors by 10% within 30 days. Too specific. Preselecting the specific means by which we’ll achieve the target condition assumes we know what will work prior to testing. Where’s the evidence? More specific than a vision or True North, but not so specific that we’re left no room to iterate based on what we learn through testing.
  14. 14. #4 Root cause analysis is an iterative process. I always thought of root cause analysis as a routine we performed prior to identifying potential countermeasures. We'd use 5-Why? or whatever to identify a root cause, then come up with countermeasures to address it. What I learned through the Kata approach is that we don't have to fully understand the root causes of a problem before we can start testing countermeasures. In fact, the act of testing countermeasures (via PDSA) is in and of itself a fantastic way to identify root causes in an iterative and scientific manner. In other words, PDSA is an empirical approach to root cause analysis, that can be utilized alongside statistical and practical techniques…
  15. 15. Find the right mix of statistical, practical, and empirical root cause analysis techniques to keep the “batch size” of your RCA work at an appropriate level to reduce the risk of errors in your analysis… Statistical Techniques • Regression • ANOVA Practical Techniques • 5-Why • Ishikawa Diagrams Empirical Techniques • PDSA Testing • Design of Experiments (DOE)
  16. 16. #3 Coaching is tricky. Even though the Coaching Kata provides clear instructions on what questions to ask (the 5 Questions), novice coaches typically struggle with how to stick to the script without being too robotic and awkward about it. It's a balancing act. A Coach must be able to sense when the Learner is in need of strict structure (new learners often go off in ten directions at once and need to focus on the single next step) and when a more creative, free-flowing discussion is appropriate. Practical Coaching Tips 1. Don’t kick-off a coaching cycle w/ the 5 Questions: break the ice first to make the Learner comfortable. 2. Utilize visuals: always have the 5 Questions pocket card, 5 Routines placemat, etc. on-hand as teaching tools and visual cues for routines. 3. Expect awkwardness: it’s okay to admit that following a “script” can be awkward at first. Get it out in the open early in your engagement. 4. Go off-script: it’s fine to meander during a coaching cycle in order to introduce a new tool just-in-time or to tell a story to spark the creativity of the Learner.
  17. 17. #2 Coaching means providing a safe environment to fail. “I have not failed. I've just found 10,000 ways that won't work.” ― Thomas Edison Mastering the Kata is mostly a learning-by-doing effort that relies heavily upon repetition and deliberate practice. The Coach should foster an environment that allows the Learner to practice and fail (and trust me, in the early going most of the practice results in failure). Because 'practice' in this context occurs in the real-world (not in some classroom simulation), these failures must also be done in a safe manner that causes no irreparable harm or embarrassment. The Learner’s target condition has an achieve-by date, and that target condition is where the benefit comes from. Don’t fall into the trap of thinking that each step along the way should provide a benefit!
  18. 18. #1 When in doubt, take a step forward and reflect! Fortune favors the bold. How to get started? 1. Get a group of leaders passionate about continuous improvement and get them to read and discuss Toyota Kata with you. 2. Form an Advance Team of folks from different departments and levels of the organization and have them shepherd the overall deployment. 3. Find a sensei, someone who can “coach the coach” to help you get started. 4. Train up the Advance Team as best as you can and start practicing the Kata routines (prepare to make mistakes!) 5. Once you reach that target condition, you’ll know what to do next!
  19. 19. About the Author Michael Lombard is a seasoned leader in healthcare performance improvement. His mission is to help healthcare systems deliver ever-increasing value to patients and the community by improving quality and reducing cost. His approach is to get results by facilitating process improvement while increasing the improvement capabilities of the people in our organizations, in an effort to build cultures of continuous improvement. His goal for writing is to explore ideas and continuously improve his understanding of kaizen in healthcare settings. Please feel free to contact Michael… @MikeLombard LinkedIn mlombardjr@gmail.com

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