Sunday, November 28, 2010

En route to True North

"True North" is a key concept in Lean process improvement. It might be viewed as a mission statement, a reflection of the purpose of the organization, and the foundation of a strategic plan.

Here are illustrative thoughts from two observers:

The "ideal vision" or "True North" is not metrics so much as a sense of an ideal process to strive for. It sets a direction, and provides a way to focus discussion on how to solve the problems vs. whether to try.

If we don't know where we're going, we will never get there. "True North" expresses business needs that must be achieved and exerts a magnetic pull. True North is a contract, a bond, and not merely a wish list.

Lean is inherently the most democratic of work place philosophies, relying on empowerment of front-line staff to call out problems. The definition of True North, however, does not rely on that same democratic approach. Instead, it is established by the leadership of the organization.

At BIDMC, we have been engaged in a slow and steady approach to adoption of Lean. Our actions have been intentionally characterized by "Tortoise not Hare," as we methodically train one another, carry out rapid improvement events, and integrate the Lean philosophy into our design of work. As you have seen on this blog, staff members have come to embrace Lean and have used it in a variety of clinical and administrative settings.

(For more examples, enter "Lean" in the search box above. I have been presenting them here for some time in the hope that they would be useful to those in other hospitals who are thinking of adopting this approach.)

We have intentionally not, until now, tried to define True North, but things have now progressed sufficiently in terms of our application of the Lean philosophy that the organization is crying out for it. This is just as we had hoped. Establishment of True North before this time, i.e., without an understanding of its role, would not have been as useful in our hospital.

So, the clinical and administrative leaders recently met to try to nail this down. The process is not over. Indeed, our Board of Directors has yet to pitch in and offer their thoughts. But, we are far enough along that I thought you would enjoy seeing the draft.

Here it is:

BIDMC will care for patients the way we want members of our own families to be treated, while advancing humanity's ability to alleviate human suffering caused by disease. We will provide the right care in the right environment and at the right time, eliminating waste and maximizing value.

Here is some commentary to help you interpret and deconstruct this. The first sentence is based on the long-standing tradition of our two antecedent institutions, the New England Deaconess Hospital and the Beth Israel Deaconess hospital. The late doctor Richard Gaintner used to refer to the Deaconess as, "A place where science and kindliness unite in combating disease." That could just as well have been applied to the BI. As an academic medical center, our public service mission of clinical care is enhanced by -- and enhances -- our research and education programs. Our mission is to help humanity, not just the people who live in our catchment area.

The second sentence is offered in realization that the Ptolemaic view of tertiary hospitals as the center of the universe is no longer apt (if it ever was!) We need to view ourselves as being in service to primary care doctors, community hospitals, and other community-based parts of the health care delivery system.

On another level, it is also reflective of the fact that society expects us to be more efficient both within our own walls and in cooperation with our clinical partners, adopting approaches to work that do not waste societal resources.

In contradistinction to what I just said about this not being a democratically established statement, I offer our draft to you -- both those within BIDMC and worldwide -- for your criticism and suggestions. I don't know of other places that engage in this form of crowd-sourcing with regard to True North, but readers of this blog are unusually informed about health care matters, and I welcome your observations.


Anonymous said...

I love that it is brief, straightforward and heartfelt. I am not sure however, if it hadn't been for your comment, that I would have known the second sentence encompassed your view of:

being in service to primary care doctors, community hospitals, and other community-based parts of the health care delivery system.

I think this view is critical to your mission, especially in your area. Any way to strengthen that?


Steven Spear said...

Dear Paul,

Your definition of "ideal" is too wide of the mark. While it reads well as a motivating mission statement for an organization, it fails to do the job the term "ideal" plays within an organization capable of high velocity improvement and innovation like Toyota.

First, to the extent that lean, as practiced by many, is a loose approximation of what Toyota does in practice, this definition of "ideal" is so far from Toyota's as to be largely unrecognizable.

Second, and why Toyota defines in practice the "ideal" the way it does, your definition is not an unambiguous challenge for improvement and innovation, the role this concept plays within Toyota.

The first point first.

The "Ideal," when used within the Toyota community has a very specific meaning. Work is done 'ideally' if:

-- the output is defect free,
-- the product or service is delivered in response to customer need (pull, on demand),
-- the response is immediate,
-- products or services are provided 1x1 (in the unit size of use),
-- work is done without waste,
-- work is done safely,
-- work is done securely.

As to the second point of why Toyota defines the "ideal," in practice, as it does.

Defect free, immediate, on demand, 1x1, waste free, safe, and secure is an absolute standard of perfection from the perspective of customer, employee, and supplier.

Because it is an absolute anyone can observe how work is being performed and recognize need for improvement--even in the absence of obvious problems like scrap, delays, and the like.

I challenge you to walk the halls of BIDMC, using the the two alternative definitions of the "ideal"--the one you have written and the one used by Toyota to see which is a better framework/trigger to see opportunities for betterment immediately and without dispute.

Respectfully yours,
Steve Spear

Sr. Lecturer, MIT Sloan School of Management
Sr. Fellow Institute for Healthcare Improvement

Author: Decoding the DNA of the Toyota Production System, Fixing Healthcare from the Inside, and The High Velocity Edge.

Anonymous said...

Thanks, Steve,

But defect-free care does not cover all that we do here, does it? There is an important academic mission as well. Would you leave that out?

Steven Spear said...

Presumably, you want defect free education and defect free research as well?

For the first, if there is a clear definition of what students need to know (are able to do) upon graduation, you can see whether or not they have achieved those objectives (built in test), and have recourse to countermeasure any gaps.

For more on creating defect free medical education processes, please see the article "Medical Education as a Process Management Problem," Armstrong, Mackey, and Spear, Academic Medicine, August 2004.

As for research, for sure you want a defect free adherence to the scientific method to generate meaningful and unambiguous results?

To see problems/abnormalities, first you have do define problem/defect free/normal. That is true for biological systems (e.g., 98.6, 120/70, etc.) and work systems be they for clinical care, research, or teaching.

Steve Spear

Sr. Lecturer, MIT Sloan School of Management
Sr. Fellow Institute for Healthcare Improvement

Decoding the DNA of the Toyota Production System,
Fixing Healthcare from the Inside, and
The High Velocity Edge.

Carole Brown said...

Paul, I really like the way that you share your journeys at BIDMC here and the inclusive language that you use. I write this from multiple perspectives: as an organization consultant, a performance coach, a humanitarian, a patient, and as a person who's spent much time in hospitals both professionally (working for Novartis) and personally (as a caregiver for my Mum who suffered with myasthenia gravis for over 50 years). I applaud your goals and also for asking for feedback. So many people seem wary of asking for comments and suggestions from others.
I look forward to seeing more posts about the ongoing developments at BIDMC.
Thank you, Carole

Anonymous said...

This sounds awesome!!! I have one suggest, can you somehow include while humanizing the patient experience? By your statement, I make the assumption but if one hasn’t been on the side of the patient, it can unfortunately go amiss; and everyone can use a little reminding.

Anonymous said...

Two comments: I think that you mingle humanity with science well, but agree that the challenge - the hunger for improvement - is too tempered. Workers in a Lean system can answer the question: what have you worked to improve today? BIDMC physicians, staff and governance should demonstrate that energy for improvement through this statement.

Second, patients and families remain passive here. Significant culture change happens when institutions design work to orbit around consumer needs (see Spears list), as defined by patients. Here, you have just shifted to a new set of providers (primary physician consumers, etc.) (to continue the Ptolemy reference).

Mark Graban said...

While that statement is heartfelt and beautiful stuff, my first reaction is that it's more of a mission statement or a vision statement than a lean "true north." Please accept that as constructive criticism.

ThedaCare, for example, defines its true north as four things (concepts/measures):

- Safety/Quality (preventable mortality, medication errors)
- People (OSHA recordables, turnover, HAT scores)
- Delivery (turnaround time, same day access)
- Cost & Productivity

It seems that the key to their true north is that improvement efforts and departmental measures (and at levels in between) must align to those true norths...

ThedaCare additionally has strategy and mission statements, along the lines of what you've shared here.

Hate to nitpick over lean terminology, since you have the right spirit of aiming for perfection and being respectful of all stakeholders. As always, thanks for sharing.

Anonymous said...

I don't know how to respond to your suggestion, Mark. The Thedacare items you mention above are not motivational to most of the constituents in our hospital. They care about taking good care of people and doing high quality research and teaching. The fastest way to turn people off is to talk about productivity and cost. Those items are derivative of doing a good job, not aims in themselves.

I fear that the approach to Lean you are advocating is not reflective of the culture of the institution. While there must clearly be performance metrics (e.g., in our case, eliminating preventable harm), True North has to be a place to which people aspire.

Mark Graban said...

Paul, I'm not suggesting you need to copy the exact items that ThedaCare developed as true north.

ThedaCare also has aspirational mission and strategy statements, along the lines of what you created.

ThedaCare builds a lot of communication and leadership around those 4 true north points. Cost and productivity aren't necessarily bad, if they're brought about the right way (protecting people's paycheck and improving quality/safety - note they put that first).

What the true north concepts give them are a basis on which to prioritize and focus improvement and to help develop specific measures for different organizational levels. For example, quality/safety might mean "reduce patient falls" in a med/surg unit or "reduce employee strains" in a clinic setting.

Your true north certainly needs to reflect the culture of the institution. I guess my point is that true north (in a lean management context) often seems to be more than an aspirational statement - it's a way of aligning people and leaders at all levels.