Where do I start?

Dear Gemba Coach,

I’m the operations manager of a healthcare training company. We conduct technical training to nurses in hospitals. The president does the commercial part, and I run the operations, which is now an office of seven that coordinates the paperwork with hospitals, the logistics of getting trainers (mostly independents) to the right place, and other HR, books, and admin issues. This last year has been very difficult, and there is a worrying increase of complaints about the central team. We’ve had some inquiries about “lean healthcare,” so the president and I are investigating the topic. She’s reading The Lean Manager and I attended your webinar. It sounds very good, but very manufacturing oriented. Where should I start?

Wow. Good question. This is not so easy to reply to without actually seeing your operations, but let’s start with the basics. First, however, a warning: if you want to do it right, lean requires a fundamental commitment to improving your delivery process as opposed to just getting the work done. If you feel improvement is something you’ll do after you’ve done everything else, you will fail, as have countless others. Sorry to be blunt about this, but this is the single greatest difficulty in lean, and it requires a large mental shift. Your role as an operations manager is not to make sure the trainers are at the right place at the right time and all the paperwork is filled in correctly. Your most important job is improving every day the processes that leads to the trainers being at the right place at the right time, and the contracts filled in right first time and on time, and, I imagine, the feedback evaluations analyzed and passed back and so on.

What does this commitment mean in practice? To start with: an hour of your time per day. You can stop reading now if this sounds crazy. In fact, we’d probably need two hours to get started, but I realize there are only so many hours in the day and you’re probably already going home late. The promise is that if this daily hour is used right, the total amount of time you spend at the office should go down. But not just at first, so you will have to make some hard calls and postpone some other work in order to focus on your fist steps in establishing a lean culture.

If you’re still reading, what shall we use this precious hour for? You mention seven members of staff in your office. You will use this hour by spending 15 minutes with each member of staff (including the receptionist). Spend this time doing an individual interview with each of them every two days. These fifteen minutes will happen at their desk, in their office, cubicle or in the open plan.

Next, you’ll make a small investment in a paperboard for each staff member, which you’ll install next to their desk. This will be the “lean” work area.

Once both of these essentials have been set up, the best way to start lean is by carrying out a number of self-study exercises. You’ll have to do step-by-step exercises with each person, with a focus on the person himself or herself: their personality, their competence, and their own sources of motivation. It is key to remember that every one is different and to treat every one as an individual. Before you start, I have to warn you that you’ll find some individuals easier to work with, and some more difficult (the faces are probably already flashing through your mind). A key principle of lean is that we assume long-term relationships at work, so finding a way to work with everybody, no matter how difficult, is our own managerial problem. End of story. So buckle up, and simply accept that it will be easier with the people you get on fine with, and more difficult with the others. Getting the exercises going with everybody remains our target, whatever happens.

The first exercise is to ask each staff member to list what it is they actually do, and for whom. One of the difficulties of office work, compared to manufacturing, is that any one person does a huge variety of small tasks for many different “customers” (as opposed to producing a small number of parts for the next step in the process). This is further complicated by the fact that few office people consider the persons who use their work as their customers. They can be colleagues, or other admin staff at the hospital, or pesky, pain-in-the-neck diva trainers with a string of unreasonable demands. All of these parties are in fact customers of the process – in other words, partners, both of whom have to participate to get the work right.

In any case, the first step is to list the services we provide to whom. You use your fifteen minutes to:

1. Short chitchat about how they are, all well? Ready to start, etc.
2. Explain the exercise: list what we do for whom.
3. List a few of the most obvious tasks with their customers to start with.
4. Ask them to continue and tell them you’ll come back to check in two days time.

On your second visit, look over that list, and point out omissions and clarifications. If the work has not been completed carefully, it’s okay to repeat this exercise until it’s well done, to explain again, saying that you expect better in two days time when you’ll have a look again. In lean, we assume that it the associate hasn’t learned, the manager hasn’t taught. In other words, if they’re not complying with the exercise it’s our problem. Either they haven’t understood, or they’ve not bothered. In both cases, this needs to be addressed patiently, but firmly: you are coming back.

If the list is clear, complete, and sensible, you can move on to the second exercise: sketching out a rough process. Take the most obvious service and customer, a new flip-chart page, and sketch out the sequence of steps needed to deliver this service. This is not always obvious when people have never thought about their job that way. The other problem is that in many cases other people intervene at certain steps, which needs to be clarified. The criteria are that the list of step should clearly indicate each next step to provide the service. A temp, for instance, would not be able to know what the tasks are and how to do the job, but by reading this list, they should see clearly which next step they’ve got to do to complete the work.

You use your fifteen minutes to:

1. Chitchat about how they feel about the exercise and look at the work they’ve done since last meeting.
2. Explain that you want a sequence of next steps for every service.
3. Do it with them on the most obvious job they do.
4. Ask them to continue and tell them you’ll come back to check in two days time.

When your colleagues have clarified at least the key steps of their main work processes, you are ready to begin the lean work in earnest. Pick one process for each of your colleagues, and ask them to draw the key steps on top of a new paperboard page. Then, and that’s when you can expect conflict, ask them to diligently write down every instance where: someone complains (customer or colleague), where the step could not be achieved right at the first attempt, and it had to be postponed, or something had to be fixed in any way. At this stage, it’s important not to hurry to “improve” errors but to study in detail what goes right or what goes wrong. The important thing at this stage is NOT to improve the process right away; but to clarify with the staff member what you exactly mean by “doing the work right” and “doing the work wrong.” You use your five minutes to:

1. Chitchat about how the previous day went.
2. Look at specific instance of things that didn’t work out quite right.
3. Take one, and ask the staff member: “show me” to look into the detail of the situation.
4. Ask them to write down any instance of the same pattern occurring.

Congratulations: you’re doing lean. Yes, I know, this sound fairly different from all the complex stuff in the lean books, but nevertheless, this is the heart of lean, and Toyota’s very starting point: recognizing problems as they occur.

The next step is to help your colleagues solve these problems. At this stage you have to watch out for off-the-cuff solutions shifting the blame to someone else. The point of the exercise is to teach staff members to solve their own problems. So: (1) no investment, (2) together think more deeply about what the problem really is until the solution becomes obvious, so we can try it immediately.

In my experience of service work, if you truly spend your one-on-one time with each member of staff, you’ll find that they’re expert at getting things done in the end, but not in any organized fashion – hence the focus on “next step.” But more likely than not, you’ll be horrified by their attitude and responses to other people involved in the process. In service more than in any other work, it’s critical to remember that there are two key elements to doing any task: the work itself, and the relationship. Partners will tolerate almost any unpleasantness if things work out fine first time (after all, there is little scope for aggravation). But if things repeatedly go wrong, and on top of it all, the people are unresponsive or rude, it feels too much like adding insult to injury and it gets people really riled. Since you run a training outfit, you probably know all about these issues, and it’s well worth thinking about an individualized training plan for your staff members in how to speak with partners in difficult situations. Quick response with a little empathy usually goes a long long way in defusing tense situations – but it needs to be addressed forcefully.

Is that all there is to lean? Of course not, not by a long stretch. The next step, once you’ve got a handle on recognizing individual problems and immediately helping staff members to solve them to return close to the “ideal” sequence of steps, is getting people together for a day’s “kaizen event.” The idea here is to focus on processes that overlap several people. Usually, work gets stuck in piles while one is doing something else, which creates a lot of unnecessary waiting time for customers and partners, and keeps problems from being discovered as work moves from one desk to the other, pile by pile.

How to use this one day with your team?

1. Pick one job that overlaps several people’s work.
2. Invite all the participants in the process (including external partners).
3. Use post-it notes to get the team to draw the process as it should happen.
4. Identify main process gaps (this should be easier if you’ve worked for a few weeks with each member of staff on understanding what a problem is).
5. Spot operations that add no direct value to the outcome. The usual criteria, is what the customer would not be ready to pay for – how do we know: ask a customer!
6. Come up with a number of experiments we can try to eliminate, combine, rearrange, and simplify the process steps.
7. Follow up in your daily 15 minutes.

At this stage, you’re working on recognition and solving of individual task level problems, as well as understanding end-to-end process problems that involve several people and boundary issues. You’ve started the two main building blocks of lean. The remaining task that still needs to be set to finish your launch, is a test method to see whether you’re progressing or not. This is an essential part of lean. The easiest place to start is to pick up the phone and/or organize lunches with the customers of your processes and ask them to tell you how they feel about the work done by your team.

Here are three broad questions you can weave into the conversations:

1. What is your general impression of our team – better, worse, same?
2. What would be the three main things you’d like us to improve on to make your job easier?
3. Do you have specific instances of situations you’d like us to fix?

This should get you started. I hope it helps! One last word: I started with a word of caution, and will end with one. What do you, as a manager, look for from these exercises? Beyond strengthening your individual work relationship with your staff, you should be looking to clarify your own models or theories about what makes the job perform or not. We usually have vague, implicit theories about what makes things work or not (usually centered on people stereotypes). Your part of the lean work is to write down these theories (don’t share them, this is for yourself.) You’ve probably heard that lean is a matter of applying the scientific method to work, but wonder what this means in practice. Well, once you’ve written down your criteria for a process to have good outcomes, start looking for cases where this doesn’t apply. Specifically, look for instances where your criteria were fulfilled, and yet the outcome still wasn’t great, as well as instances where the outcome was great, but one of your criteria didn’t check out. These “anomalies” are the source of learning: by exploring them in detail, you will progressively enrich and complete your theories about work, and touch the ultimate goal of lean, which is to get every one to think deeply about what they do on the job. Please don’t hesitate to comment on my response and let me know whether this has helped or not.