Visual management: where to start?

Free image from Geralt on Pixabay

Visual management has lots of names. Variants in use can be known as flow boards or Safety boards, team boards, SAFER boards, #red2green boards, communication cells, performance walls, accountability walls, leadership control walls, ‘knowing how you are doing’ boards, performance screens and loads more besides. To my mind all these variants are forms of ‘visual management’, that help a team to know how they are doing and what needs to be done, at a glance every shift. Visual management can help to reduce communication challenges and delays; making waste, safety risks, problems and issues visible so they can be resolved early. Visual management supports an increased focus on improving the patient experience. The boards themselves can all look very different: manually developed whiteboards, flip chart and pens, carefully created excel graphs inside plastic holders, magnetised, on wheels, tablets or large touch screens or beamed images onto a wall. Large and small. Portable or fixed. Typically the process for each patient’s care is tracked visually, step by step. Often with a grid layout and red crosses or magnets used in a grid cell, where there is a delay or hold up so that it is visually clear that there is an obstacle to overcome. There is no ‘best’ way of creating them. In many ways, getting started is just that, decide where, what, who and why and have a go. Take that first step, see what you learn.

I have seen all of these types of boards used in health and care, I have also seen all of these types abandoned from use in health and care. For me, this is because whilst on the face of it, visual management appears to be about a ‘board’ and a ‘meeting/huddle’ – a ‘tool‘. Yet, visual management is really about a daily leadership and team habit, a daily process and practice to learn, helping teams to really understand what is standard work [note not ‘target’], what needs to be standard and what doesn’t, and what is not meeting standard (current agreed way of doing things in the team), what poses a risk to patient care or staff safety, and what needs to be done. Visual management is done as a team, together, sharing information to help ensure each patient gets the right care, at the right time, reliably, safely, and compassionately. (I still find it both sad and odd, that the compassionate part has to be spelt out in health and care). Using visual management in itself is a leadership act and gesture. Enacting visual management involves much more than a board and the energy to start and to sustain. It also requires choices of how and who to collaborate with an understanding of the commitment needed and careful attention to the ‘why’. This is why I used a team image in my blog rather than an example photograph of a visual management board.

To get going, find 1-2 enthusiastic teams who want to get involved, that is, if you can’t have a go using visual management in your own work in your own team (are you really sure you can’t, btw?). Your early adopters if you like. These can be wards, clinics, theatres, corporate teams like payroll or operational HR or improvement, community teams and so on. What’s important is that there are enthusiastic leaders, clinicians and staff who are committed to testing visual management out with their teams to benefit patient care. On a ward for example, this means generally that the ward manager and at least 1 consultant need to be keen and take part nearly every day for the first couple of months. Plan carefully and thoughtfully. Consider how night and weekend staff can be involved and informed, and also consider staff who are part of the wider team, but whom may not work in the area, e.g. a bed manager. Volunteers and patients can be involved too for some visual management boards, (however where there are patient confidentiality issues related to the data on the board, that may not be possible, be mindful of this).

In this phase (a month at the most), work on and describe the purpose of the board, involve teams in its design and set up, this will help to build will and patience to get it to work effectively in the first few months. Go and see other visual management processes in other settings to capture ideas and learning. Test it out and experiment with different board layouts, locations, frequency, duration, attendees, stand-up or sit-down, agendas (standard work), team responses/reactions/behaviours to ‘reds’ or incompleted actions, information/data flows and ensure confidentiality constraints and obstacles are resolved. Should teams have ‘tried this before’ and/or have an old board that looks like it hasn’t been used in quite a while, dust it off, talk to staff about why it stopped being used and what was good about it, as well as not so good, see what learning from ‘before’ can be drawn upon. (I don’t recommend imposing a new board or board layout. In my experience when I have ‘had’ to do that, it has rarely lasted, been useful or delivered any patient or staff benefit). If you hope to see a relatively quick impact on flow then choose an area with a shorter current length of stay. This could be the time in a inpatient bed to discharge or the duration a patient is receiving a package of care in a community therapy or district nursing team. This will help you test changes with a shorter time-lag to see what impact that step then creates, so you can consider what you learn from taking that step more quickly.

Get a temporary board set up first, on a whiteboard with markers, with masking tape or on a flip chart etc. Ensure you can still change it in the first couple of months. If you want to have an electronic board in the medium term, imho still test it out manually first. Just mock it up, you might miss things, that’s ok. You can add them later. It does need to be quite big, so everyone can see it (remember confidentiality tho’, it might need to be in a staff only area, rather than a public venue), and at least 2 metres away, really, so that there is space to huddle round and still read it. A manual system helps with local ownership, it is easy to change, there are no log in delays or risk of technical issues as you begin and errors are easy to fix. Everyone can add to the board too without worrying about access or edit rights. Having a manual physical board also gets more leaders out of their offices and off their screens to talk to teams about their boards. This way the subtleties, nuances and local context of the information and facts on the boards will also be shared, including all the niggles and issues, unlike a spreadsheet. Visual management can be used to encourage leader ‘gemba’ walking everyday, in a way.

Start, agree a time, who will lead, who will be at your board review, how will it work, how long will it take, what do you want a great flow board daily huddle to feel like, what are your ground rules for attendance, presence and timekeeping? Consider simple daily process metrics for the board process itself, like the ratio of reds/green; actual attendance/planned attendance; start on time/end on time; emoticons for how people feel. Don’t make it too hard or onerous or the end in itself. Keep it simple, manual, quick, track over time (a run chart is great here), make it a clear role of one attendee to collect that process data each huddle. Keep it nearby to the visual management board. Get the board including data flows, and huddle (visual management team) process working manually, then fix it more permanently with board tape or electronic programming later.

Don’t expect miracle results straight away, they will come if you persist, but incrementally not in a Big Bang and sometimes it might feel like two steps backwards before three steps forwards. Consider how you might keep learning together as a team and track your progress. Reflect each day on how it goes. Keep learning, it will take a few months for you to really hone this visual management practice. Persist. If you stop, or lapse, don’t worry, this happens to many teams/boards. Pick it up again as soon as you can and ask why, what made it tough to keep going, how might you get over that obstacle, how might you try that out and see what you learn? Celebrate your successes and your learning, share your learning with others who want to get started with visual management too. Maybe even write your own blog, I’d love to read it and learn more.

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