Hi, and welcome to Be The Flagship with our podcast host, Jeff Parsons.
This is where we tackle the day-to-day talent management challenges you face, particularly
in hospice and small healthcare organizations.
And now over to our host.
Take it away, Jeff.
Hey there, and welcome to this week's podcast, Be The Flagship.
I'm your host, the one and only Jeff Parsons, and my wife says, thank God for that.
We have another outstanding episode for you today with our guest speaker, Terry Norris.
And Terry has joined us for the month of January to speak about process improvement in healthcare.
So we're just absolutely thrilled to have Terry with us.
He's a lean consultant.
He's a lean healthcare expert.
He's the author of the book, How to Make Lean Work in Your Hospital or in Your Department.
And he has vast experience in developing healthcare leaders at all levels.
So Terry, welcome back.
We're so glad you were able to join us again today.
For sure.
Thanks for the opportunity.
So today, Terry, we're going to further our discussion on value stream mapping.
We're going to talk about root cause analysis and other tools we can use and other things
to think about in improving our healthcare processes.
Before we get into the detail and pick up from last week's discussion, let's take a
quick break.
We'll be right back.
At Flagship Talent, we work with our clients to find and place the right talent.
What do we mean by the right talent?
We mean we find talent who will commit to your organizational goals and align with your
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Talent who will perform to your expectations.
Talent who will stay and grow with your organization.
How are we different from our competitors?
We offer the lowest fee structure in the industry.
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We provide selection and interviewing support to our clients at no additional fee.
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To learn more, contact Jeff Parsons by email at jeff at flagshiptalent.com or by phone
at 1-800-530-4189, extension 101.
Okay, we're back.
So Terry, value stream mapping and root cause analysis.
So let's shift just a little bit and talk about root cause analysis because again, I'm
a novice obviously, but going back to the value stream map, is it one of the things
you want to do when you identify the barriers and all that is get to the root cause of why
you have the barrier?
But just talk to us a bit about root cause analysis, Terry, and give us your thoughts
on that and how to really get to the root cause of a problem.
Those are your assumptions oftentimes.
Okay, well if you will allow me to go back to the current state mapping and build to
that point because during that process, you're getting ready for that.
And I'd like to throw in just one more suggestion on the current state map too.
Let's use an example again of the OR.
Let's say you want to map out the turnover time.
How long does it take to change your room over?
It would depend, right?
Whether you're doing a big ortho case or whether you're doing an IK case or whether you're
doing, it would make a huge difference.
So when you pick something to map out, you want to pick something that's done frequently,
that's done frequently and it's sort of an average thing, something that you do all the
time and then you can extrapolate from that for the bigger cases, for the smaller, but
you do want to pick something specific.
Otherwise, when you start mapping, everybody will say, well, it depends.
It depends if we're doing this or we're doing this and that depends can just really waste
a lot of time and create a lot of confusion.
So be specific on what you're mapping out.
Map out one thing with one patient, one person from beginning to end and the improvements
you make.
You can bleed over into the other types of things that you do.
So when you're doing your current state map, you've got your process steps up.
We talked about you can add your communication flow, how the supplies get in this.
You can have different data points on there.
What's your manual touch time for each step?
What is your flow time for each step?
How long does it actually take?
And then you can also, you'll have identify your barriers.
You'll go through and say, well, here's a place where we spend a lot of time.
Here's a place where we do a lot of rework.
Here's a place where there's a lot of waiting, but you identify those all through the map
and that's really the beginning of your root cause analysis because you're identifying
what are the issues that slows down our current process as it is now.
Once you identify all those, and let's just use a scenario where we have, let's say 85
steps in a process and we have 25 barriers.
So you go through the team and you say, okay, well, let's look at those 25 barriers and
let's sort of, you know, basically take those off or rewrite them, which is rework, but
that's the one time I say, okay, I want to be able to see my actual current state map
and I want to be able to do this work over here.
But you take those 25 barriers and you start working on them.
You put them together.
If they have something to do, let's say with training or if they have to do with personnel
or whatever the case is, you sort of affinitize them and put them in groups.
And then you have the team come up and vote on them.
Of all these 25, and let's say we broke it into maybe seven categories now, which of
these do you think is the absolute biggest problem?
What's the number one problem that slows us down?
What's the number two?
What's the number three?
And you may do three to five of your biggest issues.
And that's important because you want to solve the big issues because generally if you solve
the big issues, most of the other, sometimes every one of the other, but most of the others
will be solved as well of those other issues.
So let's say you have the three top issues from a process that had 25 barriers and 85
steps.
You do root cause analysis on those barriers.
You put them on a board one at a time and you ask the question.
You turn the barrier into a question basically, and then you ask the question, well, why does
this happen?
And that's when you get into your root cause analysis really when you start doing the five
whys and the five whys, which I know I'm just introducing, but it's a technique where you
ask the question ideally five times to get to the root cause.
And it could be three and it could be seven.
And people that's actually ever done this exercise realize that almost never works like
it does in textbook, which is so perfectly so why does this happen?
And it works its way to the root cause.
So how to do that literally, actually, if I was teaching and I have taught many folks
how to do it is to brainstorm.
You know, if you have, you know, ask the question, why does this thing not work like it's supposed
to?
Why?
And then write down your brainstorm, everything that you hear.
And then you start putting in some sort of order that makes sense that would work your
way to the actual root cause.
And it works.
And it's in my opinion of all of the different tools that I use in root and in lean root
cause analysis is the most challenging.
And I tell people just get a good night's sleep, be ready to think on your feet and,
you know, to be able to lead the group and to find out what the actual root cause is.
So you have your issue.
You've identified what your root cause is through the five whys.
And then the next step is to come up with some sort of a countermeasure or solution.
And if you identify the correct root cause, it's almost obvious, obviously, usually what
you need to do.
So if you're successful in identifying the root cause, you're getting closer to what
you've called in earlier episodes, standard to work.
Is that right?
Yes.
And almost always, if not always, when you're trying to improve a process, you're almost
always one of your countermeasures is going to be to develop standard work.
You know, there's exceptions to everything in the world.
That's why I say almost always.
But on this one, I'm going to go ahead and say, I can't remember a time that it's ever
happened that we'd made something there and we didn't develop standard work.
So it's most likely most places, even if they have standard work, it's going to have to
be redone.
It's generally going to have to be redone.
It's going to have to be enforced or something.
But that component is a very, very large component to make things better.
So when you identify and document standard work, then there's obviously some training
that's required to train the organization or to retrain the organization on one of the
standard work practices.
This is the way we're going to do it from this point forward.
Is that right?
Generally, yes.
It's generally the steps in a process, along with maybe some notes about how to do that
step along with how long it takes to do that step.
And it can get more complicated than that with tact time and things that's very standard,
I'd say manufacturing.
But in healthcare, I tend to treat standard work a little bit differently.
I mean, the general idea is that we all do the same job the same way every time and we
continuously make it better over time.
That's kind of a broad definition of standard work.
Question for you, Terry.
In your experience, have you witnessed people, although you had standard work, they reverted
back to their old habits or their old ways?
Well, not getting into the improvement piece of it, but yes, you have to have that in-service
training and even a bigger piece of that because almost everybody that I've worked with does
the training, but then people don't follow it.
So if you don't have some sort of audit and accountability in that, in general, I'm talking
about quality people too.
You really assume you're best people.
It's just human nature just to sort of fall back into what you're doing.
So you do have to take time to train and you have to take time to also audit and to encourage
and to lead and all that to get people to follow the standard work, to get used to following
that.
And that is a big piece in changing your culture too because we're not used to doing that.
What about reinforcing improvement?
And I will say through observations, many observations, I don't recall ever, ever in
any industry seeing two people do the same job the same way without some variation in
that.
So you want people to do things the same way each time, no matter, you know, so if you
show up for an appointment of any sort, it doesn't matter who's working, you're going
to get the same level of care because people are doing things the same way.
It'll be safer, higher quality, training will be much, much easier if you have standard
work.
So yes, standard work is a very, very important component.
You can't really, in my opinion, it's hard to be consistently better and consistently
improve things over time without giving attention to standard work.
Yes, and that's, you know, what tends to happen, which is, you know, part of the rapid improvement
and part of the training, the understanding is generally there's a dip in performance
a little bit just in the beginning because people are having what they're used to doing
and to just doing it for 20 years or more, 30 and everybody has their different time
span, but they've done some a certain way for a long time.
So now they have to consciously think about it and follow the steps.
And the idea is not that you sit with a piece of paper every single time you do, you know,
some basic functions and you have, but you do understand, you learn what's on that standard
work and then you learn to follow it as it is.
And you don't have to look at it every time because you memorize it after you've done
it multiple times a day, day after day.
Well that's right, you know, and it's all about effectively, you know, managing the
change and I do an exercise when I'm facilitating change management training and it's really
funny as you take them through the steps, really you're taking them through the steps
of change, they just don't know it yet.
And at the very end of it, they almost always revert back to what they were doing, even
if the change is better, even if the change is more comfortable for them, people just
tend to revert back.
They'll pull out that old form out of a locker or out of a desk drawer and you never know
when I might need it again.
So you're right.
It takes, you know, it takes leadership's commitment to holding the organization accountable.
Absolutely, and even to add to what you just said because it's the team, a team says, you
know, they're excited about the change.
Leadership comes in and says, oh my goodness, this is great.
Now this will say this is a Friday.
Everybody's all excited about the change.
I mean, I'm proud of it, it's celebration.
And then they go right back, fall right back into what they were doing before.
And I thought that was fascinating in the beginning.
I'm like, you wanted to do it.
It was your idea.
Everybody agreed on it.
Your leadership thought you were a genius, you know, and then, oh, at least we understand
that.
So we know on Monday we have to be ready because it's going to be a tendency for people just
to go back and do what they were doing.
Okay.
So talk to us about future state mapping.
Okay.
Future state mapping.
So you've done your current states, you understand it, you know your barriers, you've done your
root cause analysis, so we know that we're going to take our solutions that we came up
with during our root cause analysis and we're going to incorporate that into the future
state.
So the future state generally, as long as you didn't change your first and your last
step, your scope stays the same.
You put that on the board, your first step, your last step, you incorporate your ideas
where you know that you've made changes.
We assume now our standard work is in place and we assume that we've moved this machinery
around and we've organized, we've done things that's going to save a lot of time.
And we build that map based on that assumption.
And then we ask for everybody's ideas, you know, like what else could we do?
Now this isn't just everybody.
These are the experts.
These are the people who do the work day after day after day that are directly involved in
that process.
And generally, a lot of those people have had great ideas for years and this is the
first opportunity they really had to say anything about it.
So we take our root cause analysis, we do some other training about, you know, standard
work and we do training about mistake proofing.
But we get people in the idea of understanding like some of the things that would go into
a future state map.
So then we map it out and then we challenge it.
We talk through it, we challenge it.
We're like, well, could we do this?
Couldn't we do this?
I mean, the way we've got this thing built, we've, you know, our goal was to reduce something,
let's say 30 percent.
But if we follow through just as it is, we're not going to meet that goal with, by the way,
it's usually far exceeds whatever the goal normally.
But if that happened, we would go back, we would keep working and trying to find places
where we could make a real change, change that we can do, not something that's crazy
or costs, you know, an exorbitant amount of money.
They would keep working with a future state map until it meets our goal, until whatever
targets we set in the beginning, we're confident if we do that, we can make it.
And then we map it out.
And then, of course, we're not to get ahead, but, you know, to map it out, to get it, to
make it work, you got to have an action plan, right?
So we build an action plan based on the things we need to do to make that future state reality.
Okay.
Now, earlier, you mentioned future state mapping and you mentioned ideal state mapping.
So what's the difference between future state and ideal state?
Wouldn't your future state be the ideal?
Oh, that's a great question.
And it does create confusion, especially just throwing it out and talking about it like
I did without it being a part of a, you know, train, even during the wrap and improvement
event.
We do a little bit of training, then we do a little training, then we do.
But an ideal state map is different.
So it's, you do that before the future state, you do that between recourse analysis and
the future state map.
Because at that point you said, okay, let's pretend like there's no boundaries, there's
no rules.
You can do whatever you want.
And we want to make a future, we want to make an ideal state, something that would be perfect.
So you separate people into small groups and you have them generally draw and there's different
ways of doing it.
But I generally have them just draw pictures, very few words.
What would it look like in the future?
With an ideal state, what would it look like?
And they're usually impossible.
You know, they're things that are not reasonable because, you know, you tell people that there
are no barriers, which is funny too, another whole conversation, but it's hard for people
to imagine no barriers.
That's an exercise, that's a fun exercise.
So people even for 10 minutes can't put out of their mind barriers.
We just, it's something else.
But anyway, so people build these things and we take a look at them and we have them explain,
we put them up.
Okay, everybody does a little back brief.
This whole exercise, if you do it right, it shouldn't take that long.
You spend 10 minutes building it, you know, a few minutes presenting it.
But as you're presenting it, as the teams are, they'll say, well, in this future state,
let's say from the emergency room, for example, the patient walks in one big room and in that
room is the doctors, the lab, the cardiologist, everybody, the radiologist, everybody that
you need is already there.
They're just waiting on you, you know, in an ideal state, there's no waiting.
You just get helped with whatever you need right then as an example.
So as a leader, a facilitator, you'd ask the question, well, what makes that better?
And you'd say, oh, there's less waiting.
So you write down a theme.
In this ideal state, there's less waiting.
What else?
Well, there's standard work.
There's, you know, the time it takes, it goes from four hours to 30 minutes, whatever.
When you jot down all those things for each of those ideal states and what that does,
you say, okay, well, let's take these themes, you know, standard work, doing things faster,
one touch, and let's help build that into the future state.
So it does that, but bigger than that, it really gives you the team a mental, you know,
it opens up their mind a little bit.
So they're not looking at work the same way they've looked at it for the last 15, 20,
30 years, like, okay, what could we do?
The idea is to sort of motivate people, give them that touch of creativity just before
you build a future state map to open up their thinking a little bit.
It's a wonderful tool, widely underused.
You know, most places that I've introduced it, I'm the one that introduced it because
it wasn't used before, so, but it's a great tool.
Yeah.
Thanks for that discussion.
Thanks for that explanation, Terry.
I know this is not a tool, but I know you have referenced it multiple times in previous
episodes and you mentioned it earlier in this episode, but talk to us about, it's another
one of those Japanese words, I'm afraid, but the gimbal walk.
What exactly is that?
Okay.
So gimbal walks or, gimbal is a Japanese term, another Japanese term, and a way to describe
it I think is it's the place where the work is being done.
The gimbal is where the truth is told.
It's where the facts are discovered.
It's just, you think of it literally, it's where the people are out doing the work.
So if you're doing work in the lab, the gimbal would be where the person's in the room taking
blood, you know, the part, it would be the person that's doing the work from interacting
with the patient or they'd be doing the work in the lab.
That's where the work is being done versus a conference room.
You're actually going out to where things are happening.
So that's what the gimbal is.
And so that happens how often?
It depends.
So if it happens, if you're a frontline supervisor, it happens every day.
It happens multiple times throughout the day.
If you're a director, it should happen every day.
If you're in the C-suite, you're a CEO, CFO, it should happen at least weekly.
You should be on the gimbal interacting.
So it depends on what level you're at in the organization.
And you know, I've heard the concept before, learning to see, right?
And learning to see what's really happening in your process.
And I'll give you an example.
I had a job candidate I was interviewing for a VP of operations role and she was a lean
champion.
She was very strong and lean.
It was manufacturing.
And she mentioned that an employee from a different department walked up to her one
day and said, hey, I have this problem over here and I have a leak.
I have a water line or a hydraulic line or something like that.
It was leaking and I need to have something done about it.
And she said, well, why are you coming to me?
And the employee said, because I know that you get things done.
And so the person walked, the leader walked over to the process with the employee and
saw the leak.
And the fascinating thing was they had the organization, the company had invested tons
of money in upgrading her process.
I mean, they had some new work areas and workflows.
I had invested a lot of money in that process, but they left a leak, right?
And it was like, how did you invest that type, that sum of money, but you overlooked this
one little thing that was that employee's worst nightmare.
It was really a pain for her.
And can you talk to us a little bit about how Aline?
Yes.
And I'm assuming tying it into gimbal walks as well.
But yes.
So that example you gave was a wonderful example, really, because when people just generally,
and this is across industry as well, I've had the opportunity to work in different types
and that helps me see that some things are very common across industry.
But we, I say leadership, generally tends to make decisions in the conference room,
in meetings and things like that, now teams.
But they're gathered with their folks, they ask questions, they get information, they
make decisions.
Well, what a difference it is when you get up from your desk and you go out to where
the work is actually happening.
I mean, it's shockingly different.
I mean, it's like your whole perspective of what you thought changes almost every time.
So developing a culture where your people, leadership actually do that is, you know,
it's a challenge like everything else.
I'll give one example and if I'm not answering your question exactly, please come back to
me on that.
But I just worked relatively recently in a very, very large system and they were very
much on board with doing the work, having the departments do the work, value stream
map and root cost analysis, you know, making changes that are important.
But the one thing that the senior leadership was not willing to do was gimbal walks.
They thought this whole idea of lean was fine for the people that worked for them.
And they had some engagement, so I don't want to make it sound so negative, but the one
thing they would not do is gimbal walks.
They would not go out, they would not commit to going out into the areas that they owned,
you know, that they led once a week.
And you know, some people believe that if you don't do the gimbal walks, nothing, you
will never.
That's the key.
That's the glue that holds everything together.
Some people believe that strongly in the gimbal walks.
You have to go out there to where the people are.
So to change a culture, to get people to do that, it takes the CEO back to the CEO from
a previous conversation, you know, we had, but the CEO has to say, okay, we're going
to do this.
We're going to set time aside every Friday from nine to one.
I want all C-suite folks doing gimbal walks in your areas.
No meetings during that time.
There's nothing else.
Don't put anything else on your schedule from nine to one on Fridays or whatever, you know,
something like that.
But they're dogmatic about it.
They make people do it.
They, you know, whenever you say it that way, it sounds so negative, but it's mandatory.
You have to do it.
It's part of how we're going to change our culture, you know, and you don't necessarily
present it that way, but you have to, it has to, you know, people have to do it.
So the gimbal walk is a very big part of changing the culture and without it, you're going to
have it, it'll be, you'll be hard pressed to really make any lasting changes, much less
continuously make things better over time.
You have to go out there.
So Terry, when, when you're putting together the rapid improvement event team, how do you
determine who should lead that team?
You know, let's just assume that the improvement is in a department, which it almost always
is in a department of some sort.
I believe the department leader should be the team leader because otherwise, you know,
again, it's, they, they're responsible for that department.
So if they're not the team leader and they delegate that or something, then they're not
engaged, they're not involved.
And if it's my department, I should want it.
I don't want people doing things, making, you know, making, I want input, you know,
and some people, some people may say, and they, and that there is a point sometimes,
like if the leader's in there, the leader will, you know, can influence everyone else's
comments and decisions, especially if they're a really strong leader that has, you know,
a strong opinion.
And, but as a facilitator, we know that we watch for that and we try to, you know, take
measures, mitigate to mitigate that altogether.
So that doesn't happen.
But to me, it's the department leader.
Okay.
And that's a great point about the value that a facilitator brings to the process because
you know, leaders are different and then, and the team dynamics are different.
Right.
And so if you have a very strong leader with very strong opinions, it could negatively
impact the success of that team.
And so having a facilitator who knows how to facilitate and guide the team through the
process adds, brings so much value.
And I just, in my experience, I know that oftentimes, you know, people are reluctant
to bring a facilitator in, but it just adds so much value to the process and making sure
that the deliverables are met.
So what about the team members?
The other thing that I see is that oftentimes the team leader will say, okay, I need to
involve everybody because if I don't involve everybody, then someone's going to get their
feelings hurt.
And then you bring the team together and some of the members of the team don't know enough
about the process to be able to contribute effectively.
So what has been your experience and how do you determine who the right team members are?
Well, we determine the right team members by using that side path that I mentioned earlier.
We hit all the major processes, the major steps in the process, and then we say, well,
who does that?
Who does that?
You know, who does triage?
Oh, it's triage nurse, you know.
Who does the initial exam and the medical, you know, the physician?
We work our way through and we're like, okay, we need a triage nurse.
We need an emergency room tech.
We need a physician, et cetera.
We need someone from the lab, someone from radiology, because those were all steps in
the process that we came up with.
That's how we determine the positions.
And then we ask leadership, you know, pick people that you think that will more likely
be engaged or pick people that are engaged, that would be engaged in, and influential
back when they go back out on the floor.
And we take other steps to try and involve everyone in the entire department, but not
during the rapid improvement event.
Example, two weeks before rapid improvement event, we'll put up a board and we'll say,
okay, well, we're trying to do this.
This is what we're trying to do.
Do you have any suggestions or ideas?
Or what do you think the major issues are?
And we, for two weeks, we ask people to add their comments.
That way everybody at least has a hand.
They have something to say, they have some input.
And we bring that with us to the rapid improvement event.
And that helps involve everyone without everyone being there.
And most of the time you can't shut down operations.
So if you have a department of 15, usually a couple of people will come and everybody
else has to stay and do the work.
Now if you have a small, like we're talking small healthcare sometimes, and occasionally
you could.
But if you have a small team, your whole entire department's eight people, you could do something
on a weekend or you could do something like that and you could include everyone.
But generally that's not how it works.
Got it.
That's a great approach by the way.
I mean, that's great.
So when you bring the team together and you're exposing them to these tools, the value stream
mapping and the five whys and root cause analysis, all these things, do you provide the training
upfront before the team gets started, before the rapid improvement event begins?
Or do you provide as a facilitator yourself or do you provide training on the go?
You know, basically just in time training.
How do you approach that and teach people how to use these tools?
So I'll start it with a story, so when I first got into Lean, very first, the organization
that we brought in, basically we did the training in advance.
We did it and what we realized right away is that not everybody showed up.
So after doing that one or two times, it was obvious.
I'm like, you know, I was a leader.
I was the director of the department.
Like we're not doing this.
Yeah, we're good.
We're not going to do this.
So now since that's 2006 or seven maybe.
So since that time, we always do just in time training.
You know, it's like we're getting ready to do a current state map.
We do a little bit of training.
We do a current state map.
We do root cause analysis.
We do a little bit of training.
We do root cause analysis and most of the tools lend themselves to just that.
You can do a little just in time training and people can successfully maneuver through
them.
That makes sense.
So let's take a quick break.
We'll come back and wrap things up.
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Okay, we're back and I'd like to wrap this episode up with a few things.
First when we talk about process improvement and we've over the month of January we've
emphasized lean in healthcare, but lean has other applications other than in clinical
care or operations, right?
We like to think that it's sort of narrowly focused on operations, but it's also very
applicable in administrative functions such as HR and finance and other administrative
functions.
In other words, if you have a process you can use the same tools we've been talking
about this month to improve your processes, to improve your effectiveness and your efficiency.
Give you a couple of examples in finance.
How many days does it take to close your monthly books?
What's the process for it?
It is a process.
Can you improve upon it?
HR, what's your time to hire?
How long does it take you from the time of an employee requisition to the time that that
person starts on the job?
That's a process.
Can you improve upon it with the tools we've talked about this month?
Yes, you can.
And so think of it in the broader terms of how can I take these tools, even if I'm not
in clinical care or any other type of operations support, how can I take these tools and use
these tools to improve my processes and improve my performance and the performance of my team?
Those are the important things to get out of this month's episodes.
And also I'd like to leave you with one more process improvement quote for the month of
January where we have focused on process improvement.
And although this is an improvement quote, it's not necessarily process driven, it's
people driven.
And remember, be the flagship is about talent and process improvement is about talent.
It's about managing talent, managing change.
So here's the quote, it's by a person named Melcher Lim.
And his quote is, there is no exercise better for the improvement of our world than reaching
down on a daily basis to lift someone up.
No truer words have been spoken.
So there's no exercise better for the improvement of our world than reaching down on a daily
basis to lift someone up.
With that, Terry again, thank you so much for your contributions in the month of January
on process improvement and healthcare.
I truly appreciate you.
For our listeners, remember you can find his book on lean healthcare.
The book is titled, how to make lean work in your hospital or in your department.
Doesn't matter if you're a hospice, home health, other small healthcare, those tools apply
to your organization.
So it's a great book.
You can find it on Amazon again, by Terry Norris.
Terry, thank you so much for your contribution and you have an open invitation to join this
podcast.
Thank you so much.
Thank you too.
Bye bye.
Thank you for listening to this episode of Be the Flagship with Jeff Parsons.
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Until next time, take the step to become the flagship in your marketplace.