“APAGOREUETAI TO KAPNISMA”
Or, how about
“VIETATO FUMARE”
Well, okay then, what about
They all mean the same thing, but unless you speak Greek or Italian, the first two instructions may not have been clear.
“Status at a glance.” You have no doubt heard the term many times when discussing visual management and the fundamentals of Lean health care. What does it really mean, and how do we ensure that the tools we are implementing truly are telling the story our picture intends? Manufacturing has focused on visual management for a long time, but how does it apply in Lean health care? The key objectives of visual management are:
- Give the status (indicator lights)
- Direct and locate things (road signs)
- Indicate actions (traffic lights)
- Show what is right or wrong (lines in parking lots)
Although each tool has a different objective, the goal of all visual management tools is the same: status at a glance. For a leader, especially a leader in an organization on the pathway to a Lean transformation, visual management is one of the most fundamental and necessary elements to success. The gemba is focused on coaching and reinforcing the behaviors of our employees that support our departmental objectives – which are driven by our strategic initiatives. The gemba is about observation and our observation is greatly enhanced by the ability to see the status at a glance.
I was recently in a hospital in the United Kingdom in the early stages of a Lean health care transformation. One of the Lean facilitators for the institution stopped at a visual management board in the hallway to explain what the board was telling the hospital leadership and employees. The important thing was that he didn’t need to explain the board. I was able to look at the board and at a glance know where the questions should be directed. The status of the metrics was easily seen by the simple color coding of the days of the month to indicate whether the goals were achieved. The board clearly specified good versus bad on a daily basis with the red and green status. I was also impressed that a staff member who was passing by was able to articulate the function of the board as well as the meaning for the employees. This was a visual management tool that was doing a very credible job of status at a glance.
A visual management system in a Lean health care organization is critical to
- Give the status of the process
- Direct the leadership to areas that need support
- Indicate the actions or countermeasures that are in process
- Show normal versus the abnormal, or what is right and what is wrong
When creating a visual management board, a simple four by four matrix is a good place to begin. The columns reflect the key indicators of the value diamond of a Lean health care organization: Satisfaction, Quality/Safety, Cost and Time. The first row reflects the History – a run chart of a key indicator for the unit. The second row is Pareto – what has been determined to be the primary influences or root causes of the failure to meet the goal. The third row is Problem Solving – typically an A3 depicting the cause or causes that the unit is working on. The fourth and bottom row is the leading indicator data depicting the countermeasure from the A3.
When assessing a visual management board, the criteria are:
- Evidence of visual management practices
- Evidence that the information within the tools is maintained and current
- Measurements include goals/targets (expected) and actual results
- Reasons for “misses” are documented and are driving continuous improvement efforts
- Evidence of a system of standards, andons, and responses
- Modifications and updates as conditions change
A colleague of mine has an example that explains this very well:
A unit in a hospital was struggling with discharges. The goal was 80% discharges by 10 a.m. The run chart showed they were averaging only 40%. Pareto analysis showed the number one cause was patients not being ready to be discharged at 10 a.m. When an A3 was worked through to give more detail it was determined that patients didn’t know they were leaving on that day and time and they didn’t have transportation arranged, among other obstacles. The countermeasure the team decided on was to utilize the whiteboards in the patient rooms to update them daily with the prospective discharge date and time for the patient and the patient’s family. This countermeasure’s data was gathered by the charge nurse in normal rounding and entered directly to a chart on the visual management board (percentage of boards updated that day).
This now provided a leading indicator that could be tested against the overall defect of the failure for timely discharges. In fact, this countermeasure was very successful and subsequently the overall metric did show dramatic improvement.
Rod Stewart (I’m aging myself again) sang that “Every Picture Tells a Story” and he was right. We need our pictures to tell the story intended, in a simple focused manner that our employees can easily understand and, just as importantly, be a driving force for the problem solving that is integral to continuous improvement and Lean health care transformations.
