Persisting to learn: persisting to practice

I’m writing this blog whilst waiting for my daughter to graduate with her next Tang Soo Do red belt stripe. I think she will then have about 3-4 more stripes, before she can try to attain her dark blue belt. This is the first pinnacle, the first master belt: 1st Dan. Amongst other things, quite impressively, you have to break a brick with your bare hands to pass. From my parental perspective, it will be quite an achievement and I, naturally will be very proud.

It has been a long road. She started Tang Soo Do roughly the same time as I started my thesis, 5 years ago, and that at the time felt like forever to me. Then, as now, Tang Soo Do graduation is dominated visually by white, yellow and orange belts, (especially in the car park!) These are the colours of new enthusiastic learner belts maybe 3-6 months in. There are noticeably fewer green, red and dark blue belts, representing higher levels of accreditation. These later levels, like in computer games, take more effort, time, persistence and practice to complete, and perhaps provide fewer adrenalin shots of euphoria to keep you motivated each time, as levelling up becomes less frequent.

It is a lot of time, money, attention, persistence and most importantly, practice to reach real competence in a new skill. Practicing the same moves, routines and forms, over and over and over again. In fact, the practice can be so repetitive, my son, once the most enthusiastic Tang Soo Do attender, as it was so exciting to learn to fight, now refuses to go because it is ‘too boring’… (and Fortnite practice instead calls too much).

I reflect on this because over the last year, I feel that I have really noticed a growth in dialogue in the improvement community about the importance of habits and regular and repeated practice to really ‘get improvement’. To learn the tacit knowledge and mastery over time, that sometimes seems so difficult to grasp.

You may have read some if my blogs about Kata, a practice which emphasise repeated short bursts of daily practice in improvement experiments and leadership coaching, whilst following, at least at first very prescribed routines. These ‘starter kata’ routines are recommended to be followed rigorously for at least 3-6 months through daily practice before any substantive localisation and adaptation. They are also recommended to be learnt through practice, rather than through the classroom.

This approach is in part is aimed at un-learning previous (perhaps bad) habits and to create new neural networks and new habits. The process mimics that of learning a new musical instrument with 30 mins practice a day, and so you might be able to get to Grade 1 within a year or so. It is hard to stick to. Persistence is important here, not just intent, as knowledge of kata is most definitely not understanding. Daily work, crises, extra meetings, and many other things (arguably excuses) can all get in the way of daily kata practice. This daily improvement practice too can lose its shine of newness and move into something a little less exciting as it becomes more routine, which is ironically its aim.

Similarly the 6 Sigma (and Lean 6 sigma) approach to improvement uses a karate-like ‘belt’ accreditation system, with white, yellow, green, black and master black belts. 6-12 months to green belt (classroom & a ~six month project with results), with the time taken to reach master black belt being several years. So, I get to my point. Notice the kind of timeline we are talking about here… grade 1 within a year. 6 months to a year for green belt, at least 6 months to practice starter kata. These are not short time lines to become reasonably proficient, never mind an expert.

Yet, as noted in recent research often healthcare leaders and teachers have sometimes assumed that improvement knowledge and skills can be: a) predominantly taught in a classroom (or virtual classroom); b) can be taught quickly, say a couple of days worth of content; and c) participants will be able to apply and contextualise this learning with pretty much immediate effect and show results quickly. For me these widespread assumptions are An oversimplification of improvement practice. After, many leaders seem to be disappointed to discover that many learners do not the use their new learning, question its appropriateness and content and, with some exceptions, results don’t often follow. Participants often reflect that ‘it wasn’t as easy we thought‘.

This, for me anyway, suggests that ongoing support, on the job learning and ongoing learning in practice with coaching, apprentice style, is needed if we really want to develop organisational wide improvement capability and learning cultures within health and care. Much like in places lauded like Toyota, and increasingly within healthcare organisations such as Intermountain.

To improve something both as complex and important as health and care, we need to ensure not just the teaching of improvement, but also the ongoing practice in the application of improvement approaches to develop our equivalent of black belts and Grade 8 improvers – mastery. Not just lots of Grade 1s and 2s, white belts and yellow belts, learning a little bit, as important as they are for everyone to participate in improvement and to develop a next generation.

We need this wider recognition of the need for this practice of improvement approaches, if we are really to embed improvement practice and mastery within health and care. Even if practicing is less exciting, more mundane and less new over time and as my son would say, ‘practice is boring’.

But then again, my daughter says, ‘it might be boring, but practice is worth it’.

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#Quality2019 : my reflections

I was lucky enough to be one of the 3500 or so delegates at the BMJ/IHI International Forum on Quality and Safety in Healthcare (the ‘Forum’), held in Glasgow last week. The annual conference held in Europe can be argued to bring together the European healthcare ‘Improvement’ community and a few others from slightly further afield, typically from the USA and the IHI. There are arguably other conferences that might cater better for Lean practitioners, (such as Lean19, on in the USA concurrently), improvement scientists, regulators, and other role variations of ‘improvement in healthcare’. Nevertheless, in many ways this particular conference has to my mind become the market leader in bringing quality improvement (QI) to the healthcare masses, in particular, leaders and practitioners. Well done and thank you for all that this Forum contributes. I felt it was a great success and the Scottish venue was excellent, (certainly better than the Excel in London… speaking in the non-biased English way, that you can only have when you grew up only 8 miles south of Hadrian’s Wall! 😉 ).

This year, the theme of the conference was ‘People Make Change‘. I rather liked this, especially the use of the word ‘make’, rather than ‘deliver’ or other words that might have been subtly more coercive; and I liked that ‘make’ is a verb, implying action and thus for me the idea of continuous improvement. There were many super keynotes, in particular from Nicola Sturgeon, First Minister of Scotland (and former Scottish cabinet secretary for health and well-being [note that emphasis]), who demonstrated the kind of improvement knowledge that many of us wish more healthcare leaders might aspire to develop. Other highlights included Henry Timms speaking about New Power, and the conversational ‘I have changed my mind’ morning session from Don Berwick and Maureen Bisognano.

I rather liked this conversational and surprisingly informal morning session, which covered a number of topics including mental health, what matters to you, measurement and kindness. I certainly felt inspired enough to consider that maybe we can start to build some kindness PDSAs into our improvement work. I also really liked the messaging the topic area gave, i.e. it is ok to reflect on the evidence and what you have learnt and change your mind. That is, use your critical thinking skills, it helps! What I also liked, this time, was a bit of a step towards more strategic improvement work at the meso and macro level, not just micro projects. With more emphasis on the conditions and context that support or hinder improvement and how they may be tamed, strengthened, different for different health needs and assessed (this last area being of most interest to me due to the overlap with my thesis research).

I also heard of some super work continuing around the world: on waste reduction from Australia, Joy in Work in England, emergency care improvements, growth mindsets, patient co-production approaches from many places, the Scottish daily mile, the use of Quality Management systems in Scotland or patient safety in the Netherlands and Sweden. I wish there was more time to hear more, and read more, of the substantial number of posters presented at the forum. Mine is below. Next time, I hope there might be a contribution possibility on new improvement habits that might help to sustain change supporting improvement capability.

I have been to, and/or had work shared by my teams at this conference since at least 2008 now (we won best poster for our lean based Trauma improvement work in Bolton… it seems a lifetime ago!) In addition, I have been lucky to be able to attend in person for the last 4 years on the trot, first with my research and then with work. Some things about the Forum do frustrate me. Such as a rather lack of critical thinking of what is presented by delegates and lack of opportunity to challenge presenters, which is perhaps why I liked the ‘I’ve changed my mind’ session so much. Other frustrations include: the presentation of much of the improvement work as scientific, yet a rather laid back approach to rigour in results reporting, the lack of reported limitations; the sometimes questionable methodological fidelity; and the rather surprising lack of an evaluative approach to the improvement work presented. In addition, some speakers could now be described as ‘frequent flyers’ and it is, to my mind anyway, rather expensive and perhaps even exclusive, for delegates to hear from many of the same individuals in sessions each year. Is not an aim of the conference to spread and share improvement including improvement leadership?

Don’t misunderstand me though, to be clear, I’m not trying to ‘throw shade’ on the Forum. I’m just make more personal sense of it by reflecting on it, and in the spirit of improvement, and kindness, offer thoughts on areas that can still be strengthened, whilst still appreciating the uniqueness the Forum brings. There are lots I very much like about the Forum. In particular, the significant opportunity to reenergise, reinvigorate and reconnect with colleagues, the opportunity to hear stories about improvement in practice, and how practitioners have dealt with the many different facets of context that somehow seem to become obstacles whilst experimenting on the ongoing quest to improve care.

I also love the opportunity to meet new allies and friends and I am so grateful to be able to debate with people with differing views, (I probably like this debating the most). And it is this relational side of the conference, through networking and sharing food and time, that I feel I benefit most from the Forum. It is my view that it is the strength of our relationships, that in the end, make such an impact on our improvement outcomes. In terms of bringing more and more people into a world of improvement, encouraging involvement and action, through new relationships, the Forum is perhaps not bettered elsewhere. Thank you again.

What are my hopes for a future Forum? That the spirit of friendship, networking and relationship building goes from strength to strength and with that, the Forum continues to explore how to strengthen its inclusivity of different and emerging voices, and diverse perspectives of improvement into its programme. I hope this will help to amplify new approaches, think about better and new ways of building improvement practice and habits, and create more space for healthy debate and constructive challenges and many, many more ways to improve care. To not only make change together, but also strengthen our learning together.

Right, I’m off to practice my new habit of a daily mile. Roll on the next Forum.

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Improvement brands: Why, for what and for whom?

I read a tweet recently asking for more non-clinical involvement in healthcare quality improvement (QI) work. That, for me – ‘a non-clinician’, is a pretty shocking indictment of where the QI ‘movement’ seems to have gotten to. To a point where some perceive that QI can be seen as being for clinical staff, rather than for all. It made me stop and think, what? Why is that? How did that happen? Why is it seen as elitist and exclusive?

But then, I remembered reading an article by Prof. John Ovretveit who, way back in 1997, described the ‘battleground’ for power and change in healthcare, between clinicians and ‘non-clinicians’. In that article, Ovretveit argued how there seems to be a perpetual power battle over what constitutes quality, and thus what constitutes improvement. When in many ways, both ‘quality’ and ‘improvement’ are ambiguous concepts and can be conceptualised in multiple and diverse ways. When viewed like this ‘QI’ can be argued to be a form of value judgements from those with power seeking to make things better (for themselves or others they deem as worthy). And what ‘better’ is, is likely to be determined by those with the power. Perhaps, if I reflect on the tweet, rather like the view it contained, ‘QI is for clinical staff’ rather than other staff, or indeed patient, groups.

This reflection makes me think about why there is so many different forms of improvement in use in health and care, some of which seem to be perceived as for some groups more than others. Are they some kind of gesture or response within this battleground for power? I wonder if thinking about improvement though this perspective might help to explain the many and varied versions and brands of improvement, that may or may not be accessible to different groups.

When I say ‘improvement brands’ what I mean is the many different ‘ways’ and improvement approaches that are often touted. Such as: TQM (total quality management), BPR (business process reengineering), continuous improvement, service improvement, operational improvement, training within industry, IHI-QI (using mostly the Model for Improvement), Kaizen, lean, six sigma, theory of constraints, agile, lean six sigma, Toyota Production System, Toyota kata, Deming theory of profound knowledge, complexity theory, Microsystems coaching, clinical systems engineering, patient experience based design, organisational development/human led methods, statistical process control, audit, guidelines and standards and design thinking. Not to mention the consultancy/bespoke offerings that repackage these, such as listening into action, QSIR, the Virginia Mason lean approach, the Intermountain approach, productive ward, flow coaching, 15s30m, and so on, and on, and on. [11 lines just to list those, and still stuff will be missing]. All different improvement ‘brands’ arguably vying for ‘audience’ attention and reputation [at least by someone], and widespread application to generate the oxygen of case studies, and perhaps funding and resources, and maybe even fame and fortune and growing legitimacy, and with that perhaps also power.

Multiple improvement brands that can confuse and create barriers to collaboration through language. I have also seen cases where the plethora of approaches has stifled improvement by improvement beginners whom are unsure of which improvement approach to take, for fear of not choosing ‘the best’. I have also witnessed some organisations and leaders worrying they will pick an approach that is ‘not approved’ by the regulatory agency or region and they may invest in learning one ‘way’ to only discover they need to jettyson it later, stifling adoption of an improvement approach. Or worse, abandoning their investment and learning in one improvement approach if or when the regulatory agency picks ‘the right one’ or suggests [or requires] an alternative. Arguably Pseudo innovating yet another way of (possibly superficially) improving within that organisation.

In addition, as we noted at the beginning, there are leaders, organisations and teams that somehow seem to perpetuate the view that specific improvement ‘types’ are for some groups (staff, patient or both) more than others, perhaps strengthening the power of some groups over others. Further, a view has sometimes been given by some that some improvement approaches are for specific priorities that are ‘obviously’ more important than the perceived priority of a different improvement approach [perhaps like this stereotypical, and imho wrong, argument that I come across: lean for waste vs IHI-QI for quality]. These stereotypes and perceptions seem to me to be reinforced by the different branding, and channels to ‘market’, (application), that seem to inadvertently exclude some groups more than others and perhaps add to a view of improvement as elitist and exclusive.

I mean just how many brands of improvement do we need? How many can we come up with to try to differentiate what we do, or to say this is special for our ‘tribe’ only, or to make it really clear this chosen approach is the ‘good one’. [e.g. this isn’t about *cross out unneeded answers*: a policy objective that no one likes, cost savings, targets, reconfiguration, rebanding jobs, stuff that’s hard that no one wants to do, weekend working/7days, or a regulation thing or accountability].

It is my view, and I have argued this before on this blog, (re OD and QI and which improvement approach is best?), that most Improvement approaches have shared roots and provenance and have much more in common than they have differences. Further, many improvement approaches are iterations of previous approaches (TQM is arguably an earlier iteration of what we now call lean) or have developed further in one sector more than another (such as six sigma in electronics). Many describe the shared roots in the post WW2 era, with the work of Deming, Juran, Feigenbaum and Lewin; and there are even earlier roots from from the first few decades of the 20th Century just after Taylor, with the work of Codman, Shewhart, Box, the Hawthorne experiments, the Gilbreths, Training within Industry and Morris Motors to name just a few examples. This makes me think of just all the different ways that knowledge can grow and evolve and how knowledge builds on what has gone before.

It remains my view that whilst the branding packaging, terminology and presentation of improvement approaches can differ substantially, the core content is very similar. Improvement approaches (of whatever label) don’t just have shared history, and core content, they also have much more in common. Such as taking a process view, a focus on value for the user/consumer/patient, a focus on flow and reduced variation and importantly the importance of those doing the work in supporting team based improvement (Boaden & Furnival, 2016).

Yet, this blog now might now sound as though I am making an argument for ‘one best way’ of doing improvement, eliminating the branding, the eliteness and exclusivity, the jargon differences, the subtle and not so subtle tool differences, the emphasis on different elements, the value judgements as to priorities made based on the selected improvement approach and so on. Yet, I am not. Whilst there are obvious advantages for beginner improvers to learn and practice one improvement approach, rather than several at one time, and gain some mastery; the power for me of using improvement approaches, comes exactly from the diversity of so many ‘ways’ of improving.

This diversity, to me, means improvers can select the ‘best’ way for the challenge at hand, contingent on the circumstances such as the existing knowledge, skills, prevailing culture, ease, the challenge itself and crucially ‘for whom’ the improvement is for. And experienced improvers of several ‘brands’, can then change their approach and terminology, with the multi-disciplinary teams whom with which they are working and co-designing, as needed to suit new problems, new challenges and new circumstances.

This flexibility of improvement approach, in my view, can help to solve challenges by adding diversity through plural perspectives, each with a different view of a challenge, and by being more inclusive in who can take part by achieving challenges in multi-disciplinary, and more accessible ways. Allowing even more new ways of improvement to emerge as we learn together to solve problems and deliver improvement across all dimensions of quality, be that safety, delivery, equity, morale, experience or cost.

For me, to ensure the very best for patient care and population health, we need this diversity and multi-disciplinary way of improving, to ensure the constant evolution and improvement of improvement approaches, to prevent the ossification of improvement practice. We also need this diversity and inclusivity of both people and improvement approach, to help guard against elitism, where some groups can ‘do’ improvement yet others are excluded. We need the diversity and inclusivity to help us see old problems afresh, to achieve new challenges and to help us keep moving ‘Improvement’ forward with new thinking to help us achieve the breakthroughs we need in health and care. To improve improvement: we improvers too have ‘two’ jobs. We need to ensure the high quality application of improvement approaches across and between health and care organisations, now and for the future.

Improvement is everybody’s job.

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What can I learn from Toyota Kata and tests of change?

I was inspired to write his blog by a tweet from @mikelombard earlier this week who was trying to respond to a question someone asked him, and he was trying to explain the difference between doing ‘tests of change’ and Toyota Kata (Rother, 2009). See his response in the image below. In addition, I led new a Kata learners/coaches session this week as did my friend Ann, and similar sense-making questions were asked.

Source: Mike Lombard via Twitter

I’m no expert on Toyota Kata, I’m still learning about it, with all its hidden depths and insights (see my 1st sketchnote below, sorry, I’m not an artist, just learning everyday!). Nor am I an expert on tests of change for that matter. But these questions made me curious enough to wonder how would I answer the question and suddenly, I really felt that I wanted to know the answer to the question ‘how does Kata differ from tests of change and doing experiments?’ It made me think ‘where is my threshold of knowledge on this, and can I shift that in an PDSA by writing this blog?’ So, here goes.

Toyota Kata* is made up of two main routines: the coaching kata (CK) and the improvement kata (IK), that are interdependent (IK/CK). The CK involves 5 primary questions that a coach asked a learner in a structured way to support the mutual achievement of a Challenge, moving from the actual condition through a series of target conditions. The learner uses the IK to set up experiments using PDSA to help remove or get around obstacles on the way to each target condition en route to achieving the challenge. The IK therefore uses the Plan Do Study Act (PDSA) approach within its routine.

Whereas, a tests of change approach, usually combined with the Model for Improvement indicates: first set an Aim by asking ‘what are we trying to achieve?’ (arguably akin to setting a Kata Challenge). Second, ask ‘how will we know?’, (ie the measures trying to be achieved) and then third asking ‘what changes can we make that will result in improvement?’ The changes are then chosen through many ways from the brainstormed list (often using a driver diagram or fishbone) to be developed for action, initially through small tests of change using PDSA.

Sounds really similar so far doesn’t it? Like maybe the IK and tests of change are much the same? Both are just PDSA with some dressing around them? I thought so too, about 6 months ago, when I first learnt a bit about Kata. I also thought, oh my, it’s only 5 questions what’s the fuss all about, this is really not hard. But now, I really don’t think so. For starters, it is decided deceptive and much harder that it seems at first glance. Knowledge is most definately not understanding. And in terms of similarity, rather than difference, I am beginning to consider that Kata is the next revision of our PDSA knowledge and understanding – an upgrade if you like, on our current theories and practices of how to do PDSA. In a way, PDSA v2.0 … or even Tests of change v2.0. It is already sometimes called lean 2.0 or lean’s missing link, bringing the crucial cultural and human side of change together with a systemised improvement approach.

Why am I beginning to think that?

Over the last few years, there have been repeated efforts to try to determine the evidence base for the nascent ‘improvement science’ field in healthcare (or however you might call it). This research has highlighted a lot of problems with PDSA. Dr Julie Reed and Dr Alan Card’s excellent BMJ Q&S ‘the problem with PDSA cycles’ article springs immediately to mind. This article, together with a number of others, show the weaknesses within the use of PDSA in healthcare. Such as, this study reviewing the evidence indicating that less than 20% of studies actually using all 4 PDSA steps with fidelity.

Other critiques suggest that few people attempt more than 1 test or cycle of change and there is a tendency towards ‘project-itis’. That only using PDSA or tests of change doesn’t build long lasting improvement capability. That, the P – ‘planning’ takes too long. That there are many soapbox uses of PDSA not really linked to big organisational needs and goals, wasting effort. That few studies show that the learning from the tests is then used. That often tests start small and even if successful, remain small never scaling into mainstream practice. That there is often no fact based way used to prioritise and select the changes to be tested. That PDSA leads to long lists of changes and arguably improvement overburden with so much going on that nothing is achieved. That gaps between test cycles are too long. That there is little to no follow up by leaders after tests (they have moved on to the next fire). And that PDSA is applied in an ad-hoc tool like and superficial way, isolated, without being part of mainstream leadership and team practices.

For me, this is where Kata really seems to be an improvement, for improvement practice. It seems to address some of those critiques of PDSA, in explicit and also some subtle ways. For example, the use of the CK with the IK, ‘tethering’ the coach and learner together, seems to me to make Kata a stronger leadership behaviour and habit. A kind of shared accountability and risk-taking yet risk-managing process. Supporting the embedding of daily improvement habits, behaviours and routines, that use scientific thinking in daily [responsive] social processes. And to develop those habits, behaviours and routines, kind of ‘meta-skills’ if you like; daily practice, leadership commitment and involvement is required, rather than long gaps. These routines help leaders in mainstreaming their role and behaviours in improvement practice – leadership standard work.

The daily practice also helps to reduce the improvement overburden by using the rapid, frequent experiments to get through/past/by the obstacles one by one, rather than 20 tests of change and action plans to report and evaluate some 30 days or so later. These Kata routines, at scale, to my mind has the potential to support development of organisational improvement capability and then the modification of organisational culture. The daily practice of the IK/CK and the 5th CK question [how quickly can we go and see what have learned from taking that step?] mean that the gap between experiments has to be short, and the Kata routines themselves, help to build good scientific thinking habits, likely to improve the fidelity in the use of PDSA and thus help us to make better and more sustainable improvements to patient care.

However, I am beginning to wonder if, as well as the radically different leadership role and involvement required, if the main difference, or rather enhancement to the test of change approach, by the Kata, is that of the target condition being only a couple of weeks or so away. Unlike the ‘Aim’, ‘Challenge’ or ‘knowing measures’, the ‘target condition’ changes every couple of weeks as the learner experiments and learns how to meet it on the way to the challenge. As the target condition does change over time, the pattern of work and even the measures can change, as obstacles are resolved and learning generated.

In that sense, for me, the Kata accepts the uncertainty of achieving a challenge and recognises that we may not ‘know’ at the beginning, even if we have ideas. Thus, the second Model for Improvement question – ‘how would we know if a change is an improvement?’ is quite different and possibly implies a differing view of uncertainty. This question is still about the Aim [in a Kata sense, this still relates to the Challenge] (I think) yet there is no smaller target condition, to help break down steps to get there, whilst learning as you go. Perhaps therefore, the substantial difference is that the 2nd Model for Improvement question assumes that you already know something, whereas Kata does not.

So, now I have thought about and written this, what have I learnt? Well perhaps the question ‘how does Kata differ from tests of change and doing experiments?’ has some preconceived biases, mindset and assumptions in it. I wonder is it really hiding subconscious questions and thoughts such as ‘is Kata is better?’, ‘don’t I already know this?’ and ‘I don’t need to go through the pain of unlearning about tests of change, I don’t have time’. It is hard to unlearn and let go.

I suppose for me, I have learnt maybe change my mindset, instead of really wanting to know the differences, I am now thinking, does it matter? Wouldn’t it be cool if I just want to learn how can Kata help me be a better improvement practitioner? Suspending that judgement. Isn’t that really my personal Challenge? I can use Kata to help me become better, building on what I already know about tests of change, the good and the bad. Then, I can experiment to keep moving my threshold of knowledge about improvement practice, enhancing it further everyday by building better habits for learning. So, that’s what I’m doing, and Kata routines are already helping me in my work to help healthcare fail quicker and learn faster, everyday, to make things better for staff and patients.

What’s my next step? Well, publishing this, and learning from the feedback…

*If Toyota Kata is new to you, I suggest you take a look at this video.

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Reflections on improvement overburden

Quite recently I have gone back ‘into improvement practice’ after doing my PhD and policy jobs for the last 5 years. So back into the cut and thrust of ‘doing’ improvement work rather than thinking and writing about it. Back to many, many different (and often conflicting) improvement calls to action, so often well reported now by NHS Providers and others. National initiatives, national regulatory must do’s, regional initiatives, regional must do’s, new benchmarking and audit reports, organisational and local initiatives and must do’s, fabulous ideas from staff and patients, endless ideas from those outside wanting to help, including academics, suppliers and management consultancies. A never-ending stream of ideas on what needs to be done to improve care, so many in fact, that the how, can become confusing and overwhelming, even taking the first step forwards can seem paralysing and impossible. Just another thing to do.

Coming back into practice from the ‘centre’, I reflect that it is too easy to forget just how much pressure teams (staff and line) are under. The (often nursing focussed) research about work left undone due to simple time pressures seems so utterly true across all different work groups. In fact it is almost a wonder that any improvement work happens at all, with the seemingly ever growing demands from all angles. Never mind the additional work needed to try to fit all these different needs, asks, ideas and wants together into some kind of priority order, logic, narrative or sense, and clarity of how to proceed.

Yet at the same time, whilst there seems too much to be done, it is easy to spot waste, errors, harm and defects, and recognise the good intent and value behind so many of the asks. The very things that, if we could just find 20-30 mins for improvement work a day, we might be able to work out the how and do something about them. The work left undone such as when the photocopier stops working actually calling for the technician rather than leaving it jammed for the next person to find. Work left undone like actually adding and tagging something properly on a shared workspace, instead of filling other people’s inboxes including my own, so I and others can’t find things later, or worse there becomes several uncontrolled copies. Work left undone such as not filling in data collection sheets fully, so ad-hoc systems need to continue for longer for all as ‘not enough data’ was collected. Work left undone such as forgetting to open my outlook calendar so others can see it making meetings easier, timelier and quicker to arrange. Or staff just staying that two minutes longer with a patient answering their questions that might make their confidence and happiness to go home just that bit higher. Work left undone, such as a hospital letting a family know their grandad had been discharged so they could help him get settled back in at home, instead of having to be readmitted only hours later having not been able to get himself a drink or put the heating on.

Little things (and some big ones) you say, true, with a big impact on both time, and everyday irritation, frustration, obstacles, and always waste and potential harm. That adds up. It is precisely those kind of so called ‘little things’, that have inspired the great work by Daniel and Rachel in Bradford with their improvement movement 15s/30m to get more joy in work, by helping you do more of what you came to work to do. To meet your goals, be they personal, professional or organisational.

This idea of overcoming obstacles today, to help you and your colleagues meet your goals tomorrow, is particularly resonating. Over the last couple of months I have been learning much more about the Toyota Kata approach*, in many ways the invisible part of lean and for the last 25 years, perhaps the ‘missing link’ left out of Western attempts to copy and implement lean and/ the Toyota production system.

The Toyota Kata is an approach to every day improvement and coaching routines to support learning (Rother, 2017; 2018). It is also an approach designed to take a small amount of time each day, say 20 minutes, designed for learning that may lead to a bigger impact, one obstacle at a time. In a nutshell, it supports thinking scientifically about improvement by asking ‘if this is your bigger challenge… then what is your goal (target condition) over the next 2-3 weeks, and what is the first step to tackle one of the obstacles that you need to tackle, to achieve that 2-3 week goal (target condition)’. Breaking a challenge into the how of the first step of ‘what needs to be done’ seems much smaller, easier and less time consuming, somehow just makes it seem that much more achievable, that much more accessible and that much more motivational to me. I suspect that might well be the case for many others too.

Yet, as I write this, I think of how such ‘small’ steps might fit into an NHS (English) context, described somewhat cuttingly, as having a risk of gearing itself up to be a plan publishing house, for when the next NHS Plan is published this winter. More ideas, more initiatives, more what… perhaps even less how. How would kata ‘next steps’ have legitimacy across the health and care system, within those kinds of conditions? Where it isn’t certain what the second step will be, never mind the tenth one, as each step depends on what is learnt during the previous step. How would a Kata approach fit into a system, where grand and lofty policies, plans and ambitions of integrated care, better care outcomes, budget pressures and new targets fill the strategic narratives, think tank agendas and dialogues? Yet, Kata (at scale) might just offer this approach, by linking obstacle removing steps to grand challenges. This is it is reported, by Mike Rother and colleagues, is how Toyota has moved its improvement work from shop floor technical engineering of production lines to a mainstay of rapid strategy execution. Learning at scale, everyday, how to deliver value through ambitious challenges.

This seems to be done with little overburden for staff (notwithstanding the general critique of Japanese overwork culture) due to the self discipline of the leadership (global and factory) on global and corporate goals and programmes. Kata practices seem to be linked to corporate goals and global ambition through the lean approach of policy deployment (hoshin kanri). Limiting programme and initiative growth at the top, so that they don’t proliferate and become stagnant through overburden elsewhere.

As I learn more, developing Kata practices alongside the use of an system-wide / organisational and systematic approach to improvement (such as lean), seems to me at least, one of the ways for organisations to gradually move away from the ambidextrous narrative that suggests we all have two jobs. That metaphor in itself, to me, sounds like more overburden, even though I am confident that is not the intent behind the statement. Moving away from that metaphor might help us reframe improvement practice inadvertently from overburden, as another second thing we all need to do, but instead just how we do our job. By making improvement practice, coaching routines and leadership behaviours for learning ‘become so normal’, that the very idea of two jobs seems almost nonsensical because learning and adapting everyday is part of everyone’s job. The culture has been modified so much, through the use of Kata, that learning is inherently part of the culture, learning and improvement routines are just how we do things everyday, by everyone.

Want to banish improvement overburden? We can all be 15s30m movement makers here… all of us can think about what asks and improvement ideas we might remove or combine, saving a little up front and thereby reducing the overburden and work left undone later. Then we have more time to focus on the ‘how‘, to tackle obstacles that are currently preventing us from achieving our challenges, systematically, one by one. What’s our next step to to meet that grand challenge?’

* Thanks to the many people supporting me in being a kata learner these past couple of months. Very much appreciated.

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Matching Michigan: what can we learn from Zingermans and Mercy Health?

Last week my colleague Ann and I, were lucky enough to visit the University of Michigan in Ann Arbor to learn more from Drew Lochler and colleagues about the much lauded ‘Toyota Kata’, first described in the book of the same name by Mike Rother back in 2009. This included two site visits to Zingermans mail order and Mercy Health in Muskegon, on Lake Michigan.

I was a little curious and hugely, ‘Kata’ means routine, rather like practice routines such as learning scales on an instrument. The idea of spending a week examining improvement routines with some the best minds in the business was enticing, especially given the focus of my PhD on routines and capability. (I confess to also being a little sceptical, is kata yet just another improvement ‘brand’ or ‘fad’, repackaging the old, confusing the masses and generating a new round of books and conferences e.g. Katacon?). After a whirlwind trip to ride in a Model T Ford at the birthplace of mass production in River Rouge, and arguably lean after Toyoda’s visit there to see the moving production line, we arrived bright and breezy at the Barn of the Year 2015 (who knew you could win that?) to start the programme.

At first the kata seem remarkably simple (see above), I mean don’t these questions seem kinda obvious? Drew explained to us how the questions have much in common with A3 thinking and are used in Toyota alongside the more commonly adopted tools and processes such as kanban, 1 piece flow and jidoka. But, he explained, kata is the missing link in most improvement efforts who adopt the improvement tools, the purpose pyramids, the value stream analysis, the collaborative etc., yet fail to mimic the improvement and coaching practices to develop people alongside the tools, as these have often been unnoticed elements of Toyota culture. And that these kata (routines / practices) are critical to success, sustainability and ongoing continuous incremental improvement. Further he argued kata helps to counter the problems created through narrow and deep focussed value stream analysis and rapid improvement event lean deployments that can only ever touch a small number of staff quickly. Teach a man to fish…

So over the first 2 days with the help of a 15 piece child’s jigsaw, a small lanyard with the questions on and a tub of sticklebricks we set out to learn some new improvement routines and habits, our starter kata. We were also lucky enough to have a slightly starstuck lunch with Mike Rother to talk Kata in healthcare. It is fair to say, the kata questions are deceptively simple, the art of these questions come both in the ability to agree stretching yet achievable goals and the more specific the better. ‘The best goal (target condition) is one that will make you wanna hurl‘ the wonderful Betty from Zingermans told us.

Kata is set up for a learner, a coach and a second coach, typically through a line management chain rather than improvement experts. The process also requires a fair amount of trust and respect for people in line with one of the founding principles of the Toyota Way. Embedded in the kata questions is coaching and rapid PDSA aligning with organisational/system goals or True Norths. The questions are designed to help learners to the edge of their threshold of knowledge and just move them to out of their comfort zone whilst being explicit of the purpose and the theory of change. ‘How will you know?’, being a repeated follow up coaching question, the harder part for coaches being to stay quiet and not suggest (or worse) impose solutions.

In the second two days, we saw kata being used to solve challenges alongside more established lean practices at Zingermans mail order, and Mercy Health. At Zingermans, most redesign work and implementation of takt, flow cells, visual management etc, had been implemented and kata was being used by staff at key problem areas, revealed by these improvement tools, to ready for peak demand at Christmas, regularly. At Mercy Health, the mission control / big room (Obeya room) was set up to use the kata during the exec meetings and an open kata challenge was being used to improve the meeting itself. In that meeting the CEO acted as the learner, of her by a member of the improvement team, in front of his senior leadership team. Talk about CEO role modelling.

We were lucky enough to observe several open kata challenges in ‘lanes’ at Mercy ranging from infection control, LoS reduction and car parking. And Maurene and colleagues at Mercy ensured we got some more practice in encouraging us to be a coach on 2 occasions. In all cases the strength of making the kata explicit and part of the improvement process was tangible and emotional. We observed staff share their challenge, data (often local and manually collected) and saw PDSA frustration, success and explicitly their learning whilst verbally contacting with their coach their next step to be reviewed often in the next couple of days. I’d like to blame it on the jet lag, but Ann and I often felt moved to tears with the pride in the work, and the clear, and measurable, patient benefit.

For me, I was particularly interested in how to bring together traditional ‘event’ based lean deployment with the kata routines. Mercy had done this in two main ways. 1) through concurrent implementation to spread in areas without large event based improvement work, instead building on the enthusiasm and existing improvement work in the teams and 2) incorporating kata into improvement events in-week as rapid experiments and then throughout the 30-60-90 follow up process, largely eliminating the need for post-hoc facilitator reviews.

Indeed their ‘meta-kata’ work on improvement practices and routines demonstrated the benefits of this approach through improved sustainability and reduced facilitator time needed, especially for data collection. In fact, Mercy are now spreading kata and see reduced need for improvement events as the practice of regular and locally coached improvement practice (kata) spreads. That is not to say that improvement events are not without value, they too provide a whole system and team base perspective and are arguably quicker, ensuring change and important learning for kata to build on whilst the slower to master kata coaching and improvement routines develop. ‘Go slow, to go fast; develop your people, to develop your processes‘.

Is kata a fad? I didn’t get that impression. Does kata seem worth it? In Michigan, it certainly appeared so.

So what does that mean for me? How can we match Michigan in their use of kata? What did I learn? 3 main things: 1) I will have to unlearn some improvement habits whilst I learn new kata habits, (probably painfully). 2) Improvement events, workshops, collaboratives etc. have their place, yet kata is arguably more able to take context into account and is more engaging, accessible, successful and sustainable. And 3) many of our assumptions of what staff need to know about improvement as part of induction and beginner programmes e.g. run charts, 5S, driver diagrams, etc., may possibly be completely flawed. These 3 areas will undoubtedly also be some of my obstacles going forwards.

What I noticed was that kata learners and coaches can use the starter kata almost immediately without any QI/Improvement training. Improvement expertise can be shared by coaches on a need to know basis when a learner is at their threshold of knowledge in a PDSA cycle rather than batched in a training programme (thus also making the arguments about which improvement method is best, utterly pointless, if they weren’t already). This for me is significant in healthcare, with the inexorable rise in QI/Improvement training, certification and academies, and associated costs and waste. Kata ensures skills and improvement capability, (as a bundle of routines), is developed through practice, within the local context. Just like with karate forms, mastering the routines is critical and people development the goal, wherever they start, rather than through training per se.

So, what’s my next step? I’m so excited, it is hard to think of only 1 out of all of the possibilities. But following the kata principle of 1 problem at a time, my next step is to: identify 1 learner and 1 coach to use this concurrently in my value stream analysis next week in Lancashire (coach, is that specific enough?). What do I expect? That it demonstrates a new way to enact improvement actions as part of the event and the two participants will also find it useful (I hope).

Finally, as Zingermans would say, appreciation: thank you sooooooo much to all who shared time, learning and their coaching expertise with us on our trip, especially Drew, Sam, Toni, Mike, Betty, Maurene, and many more, and also to Dianne for sorting all the arrangements! Special thanks also to my mum and dad for looking after my kids for me during the school holidays, facilitating my travel.

Hope to keep learning with you all going forwards.

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Kanban: can we follow the learning from Pied Piper in ‘Silicon Valley’?

Youu may have seen the rather clever and funny HBO sitcom ‘Silicon Valley‘ exploring the lives of five white young male software engineers build a startup called ‘Pied Piper’. In the show, the team at ‘Pied Piper are developing their new IT products, and you may be familiar with the whiteboard often in use when they are in the midst of a massive amount of code programming. (This massive amount of code programming I believe is also sometimes known as a sprint, I think they are loosely modelling an agile improvement approach in the programme).

The whiteboard seems to represent a really simple process. At the fictional ‘Pied Piper’, this consists of three columns, one for ‘to do’; one for ‘work in progress’ and ‘completed’ (or similar wording). In each column is a number of post-it’s with a task on, all starting in the ‘to do’ column. A programmer picks one post–it from the ‘to do’ column, accepts it as his (and in this programme they are largely all male) and moves it across the board accordingly. This simple process allows everyone at a glance to know who is working on what, and how many tasks still need completing. The team of ‘Pied Piper’ plucky engineers love celebrating after their frequent all nighters when all of the post-its that detail each programming task have moved from the left hand ‘to do’ column to the ‘completed’ column.

Increasingly, I have noticed that this type of board is becoming ubiquitously followed and used in offices and other settings often referred to as a ‘kanban board’ or sometimes a ‘personal kanban board’ which increasingly has made me feel a little uncomfortable. Why uncomfortable? Because in these examples, kanban is being viewed as a simple visual management process for managing workload, and yet for me this doesn’t really resemble kanban at all, and only very partially meets the principles of kanban. In short, whilst these have undoubtedly good intent and are helpful, these types of whiteboards seem to be more workload tracking systems, than kanban systems. And I’m not even certain that a kanban boards is a good name for them. This is because for me, they lack fidelity to the practice of kanban and these boards could be more effective work organising systems through more careful application of kanban principles.

So, if we can’t follow ‘Pied Piper’ to learn about kanban what can we learn?

First, a kanban is a cardboard card, rather than a whiteboard. Each card corresponds to an amount of work/work task. So at ‘Pied Piper’ the kanban card is each separate post-it. So far so good you say? That still seems like kanban? Yet each post-it at ‘Pied Piper’ may not equate to the same amount of work… one might be a 30min task, another a 3 hour task. So how does the ‘Pied Piper’ system really help us to visualise workload?

Second, A kanban system is a card system that materialises information to ensure we can visualise flow, both material and information. Again… so far so good at ‘Pied Piper’, we can see tasks flowing across the board… but how much information can we see? Is it clear how the tasks connect?

Third, There are two main sorts of kanban cards (Balle et al, 2017):

1) withdrawal cards: these are mini ‘purchase orders’ for each task, tasks/information cannot flow to the next step without a withdrawal card to trigger the movement. This card represents demand.

2) production instruction cards: when a task is triggered by a withdrawal card, a related production card it is sent to trigger the start the the production or service task as a request to start, e.g to the programmer. This card represents the production response to the customer demand, is an extremely visual way, and helps to see blockages.

Can you see these two cards and their functions on the ‘Pied Piper’ whiteboard system? I can’t. I can only see one, which might be ok, if they have done something else in their system… but I can’t see it. I usually can’t see two systems one for demand and one for production in office systems either, yet work in offices is rarely ‘produce by only one person’ so surely some kind of ‘production order’ is still needed in response to the customer demand.

Kanban (in lean) is used as the basis of just-in-time and one piece flow, and was based on the idea of supermarkets where customers pick what they want and shelf stackers fill in the space on the shelf after they have picked their product. Kanban imposes discipline to ensure no more than needed is produced, in demand order according to the customer and kanban supports other processes linked to getting it right first time. (at ‘Pied Piper’ the programmers correct all their programming errors at the end, rather than as they go).

The purpose of kanban is to have the least possible number of cards possible in use at any one time. This minimises work in progress thus the cost of inventory and stock holding. For example, if an employee has a whole pile of task post-its, or a whiteboard has more post-its in the work in progress column than it has staff working, then this defeats the purpose of using kanban. The post-its (cards) are not being used to drive one piece/task/decision flow.

This is important because studies show that there is as much as 20% lost time as employees switch between different tasks without completing them and the risk of errors and mistakes increases. Kanban when used correctly enforces a limit to the number of tasks anyone person is doing at a point in time. This also has an added benefit for employees as it reduces overburden and the interpersonal conflicts and frustrations that can arise from resource allocation decisions.

Nevertheless kanban is also difficult to learn and use, I am still learning its intricacies, and how kanban principles can be applied in healthcare, and yet it is deceptively simple to look at and consequentially mis-understood and imho, mis-applied.

The book ‘The Lean Strategy’ (from which I have drawn heavily in this post) suggests that a way of managing office based workloads such as that in the ‘Silicon Valley’ programme might need 2 whiteboards (Balle et al., 2017, page 101). One containing ‘to do’ tasks without prioritisation, and another containing a grid sized for capacity, and new tasks can only start when an aisle is freed up (see photo below).

Photo from The Lean Strategy, Balle et al., 2017, page 101

This process controls the flow of work tasks, limiting batching and work in progress, and even more importantly, reveals where problems and overburden in workflow are. For service tasks such as programming, designing, policy making and product development, the daily practice of reviewing flow by all team members and leaders together to solve problems, reveals holds ups, errors, delays and where team members need help (do we see that at ‘Pied Piper’ or most office based systems?). It also illuminates where there are areas of over processing and overwork, leading to simpler and more elegant designs and can accelerate office-based productivity.

So whilst, I can see the attraction of simple whiteboards used to visualise workload tasks… for me at least, these are not really kanban boards, because these 3 column whiteboards fail to benefit from the potential of kanban by failing to apply the principles that underpin it. For me, the name of the board and the language used matters. Fidelity of use matters, because if other learn to use ‘kanban boards’ that do not hold true to the principles of kanban. And learners perceive them as ‘best practice’ or similar, then the benefit of such visual systems will not be felt and misunderstandings of what kanban is, and isn’t, and what it can be used for, may fail grow further. Possibly perpetuating messages of that ‘improvement’ stuff doesn’t work.

So I am not going follow ‘Pied Piper’ and use a similar whiteboard workload tracker from but I am going to keep learning to use improvement tools like kanban with as much fidelity as I can, to keep benefitting my customers, and in healthcare, our patients. If we are going to practice improvement, is it not important that we try to practice it well?

What’s your view, does fidelity matter? Am I being too technically picky? Does method really matter that much for this? Is this just a difference between agile and lean approaches to improvement? Do you disagree? Love to know!

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