The Value Stream of Succession Planning and Leader Development

by Jamie Flinchbaugh, co-author, The Hitchhiker's Guide to Lean

What's the purpose of thinking about work as a value stream? Is it just a buzzword? It helps us identify how our activities connect and flow together in order to deliver value to some customer. So let's look at the process of succession planning and development from that perspective. Succession planning as a value stream might be considered a subset of the much larger talent development value stream (see wikipedia on succession planning).

When we don't think of succession planning as a value stream, we just think in terms of the end result. The end result is knowing who will replace a key position if that person leaves, is fired, or is otherwise not available. Most organizations skip to the final result: they name one person who best fits into that role. That answers the open question on the table, but it doesn't solve the real problem, which is how do I get someone to the point that they could replace someone.

GE is an example of someone doing this right. They have systems, evaluations, relationships, goals, and resources all designed on developing leaders to their full potential with the assumption that tomorrow's division presidents and CEOS are working somewhere in the company today. When Jack Welch was getting ready for his retirement, he had 3-4 individuals that he, the board, and the shareholders all would have been comfortable as a replacement. Warren Buffett is in a similar situation, with 2-3 "deemed worthy" successors sitting in the wings. On the other hand, no one can imagine or can see anyone being groomed and prepared to take over for Steve Jobs at Apple. The naming of a successor is not just an event, it is instead the end result of a thought out and managed value stream of leaders.

As with any value stream, we must consider its design and execution in the context of the changing environment in which it operates. As it relates to succession planning, a great example is found in the privately-held family business. The commonly-accepted flow was that "dad" (it's not always dad but the majority still is) would run the business until they were in their 50s or 60s at which point they would retire. The son, daughter, son-in-law, or other next-generation-representative would then take over in their 30s or 40s with some experience behind them but also plenty of time to make their own mark and take the business to a new level. How is the environment changing? Quite clearly, each generation is living longer, and working longer. This has a dramatic impact on the value stream. If dad is going to run the business until they are 75, son doesn't want to wait until they are 50 to take over. So instead they leave and find something else to do. Now there is no one "downstream" in the succession process to take over. Right now there are many privately-held business in that condition looking for a solution in ownership and leadership.

How do you look at succession planning as a value stream? Ask yourself these questions:

First, what is the value, what are customers willing to pay for? This is defined by having a clear leadership model. There is no right leadership model, you must develop that based on who you are, who you want to become, and where you want to be.

Second, what is the takt time, or customer demand rate? You will need to develop leaders at a certain pace, and that pace is probably constantly in flux depending on your current conditions. If you industry is headed for a certain level of decline, it might not be as attractive and you have to develop people at a faster pace to replace outgoing leaders. It's just as important to know if you have a slow need for new leadership.

Third, understand the activities that make up that value stream, from initial hiring to exit. Look at the flow. Very often, there is a great deal of batching of the development of leaders centered around late in the value stream. It is very helpful to spread more of that change upstream to earlier in a leader's career. Although it is spread across more "product" that may not make it, it is cheaper and those investments have longer to pay you back.

Lastly, measure it, manage it, and improve it. Measure you pace, your success rate, and your fallout in the succession planning value stream.

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A Lean Guy Reads FORTUNE

As I was catching up on my back issues of FORTUNE, I had a few Lean thoughts as I read.

In the June 9 edition, the article "Wal-Mart puts the squeeze on food costs" caught my eye. It says:

Wal-Mart has temporarily rolled back prices on hundreds of food items by as much as 30% this year. How? By pressuring vendors to take costs out of the supply chain.

Read that again. It says "take costs out." This is different than the stereotype of Wal-Mart "squeezing" suppliers for a lower price. Demanding a supplier accept a lower price is NOT the same as real cost cutting that can be shared. I'm happy if Wal-Mart is really learning how to collaborate on real cost reduction. The article continues:

Ever wonder why that cereal box is only two-thirds full? Foodmakers love big boxes because they serve as billboards on store shelves. Wal-Mart has been working to change that by promising suppliers that their shelf space won't shrink even if their boxes do. As a result, some of its vendors have reengineered their packaging. General Mills' (GIS, Fortune 500) Hamburger Helper is now made with denser pasta shapes, allowing the same amount of food to fit into a 20% smaller box at the same price. The change has saved 890,000 pounds of paper fiber and eliminated 500 trucks from the road, giving General Mills a cushion to absorb some of the rising costs.

I've certainly wondered why some boxes (from Target) are unnecessarily big. The above sounds like a nice example of win-win collaboration and something that General Mills can do other than whining that their costs have gone up. The article also discusses how Wal-Mart is attempting to reduce transportation costs by purchasing more produce from local farmers. It might be a higher unit cost, but it's the total cost that matters, right?

I'm surprising myself that I had nice things to say about Wal-Mart.

In the July 7 edition, a quote from Barack Obama in this article caught my eye (for purely non-political reasons). FORTUNE asked:

How would your management style differ from that of the current occupant of the Oval Office?

and Sen. Obama responded:

And so I think the biggest difference in my management style and George Bush's is that I want a robust discussion around the table with a lot of different viewpoints and a firm footing in the facts. I always want bad news first. Good news takes care of itself.

This is a very Toyota approach. Toyota leaders always ask about the problems first (the "bad" news... although Lean thinkers wouldn't think of problems as "bad"... "No problems is a problem" as they say). I've also heard that Toyota leaders like to ask "what are your top three problems?" before they'll move on to talking about anything positive."

Fact-based discussion. Listening to different viewpoints from people. Putting politics aside, if this is possible in mentioning Sen. Obama, that's the essence of Lean thinking right there.

"Data is of course important in manufacturing, but I place the greatest emphasis on facts." --Taiichi Ohno

Thanks to Craig Woll for re-printing that quote. I was taught that what Ohno meant is that data (numbers in a report) are helpful, but you find real facts by visiting the "gemba," the shopfloor or the place where work actually happens (a hospital emergency department can also be a "gemba.")

I'm not saying "Ohno-bama" is the "Lean candidate" but he has an interesting take on leadership.


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Jamie Flinchbaugh Video: Daily Improvement

Everybody Everyday: Managing for Daily Improvement

The link above is an online video presentation by Jamie, courtesy of IndustryWeek (click here to subscribe to their print edition of the magazine).

In This Presentation You Will See

• How 90% of Lean strategies start and end (in minute 10)
• What you really want (and get) out of 5S (in minute 23)
• How you measure Lean (in minute 25)
• The leading metric of truly sustainable Lean change (in minute 27)
• Using lean to change the work of leaders (in minute 32)
• How to manage, not just lead (in minute 35)
• How to integrate Lean into the organization (in minute 41)
• How to know when problems occur (in minute 44)
• and more

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The Risks of Superficial Change

Rupert Cornwell: Cuban leader must learn from Gorbachev's mistakes - Commentators, Opinion - The Independent

I was reading this column yesterday and I thought of Lean and change management. As the author discusses reforms in Cuba, he opined:

Mr Castro's actions thus far have been tinkerings compared with the revolution of perestroika and glasnost unleashed by Mikhail Gorbachev. But, as he is surely well aware, in the late 1980s the Soviet Union got the worst of both worlds – at least from the point of view of its rulers.

Gorbachev's reforms broke the party's monopoly of political power, but also made the economy even more of a mess. By combining superficial market reforms with a refusal to challenge the entrenched bureaucracy, perestroika merely made an already inefficient and corrupt system even worse.

Does the same thing sometimes happen in Lean implementations? If there's a "superficial" reform, such as using a tool like 5S, without changing the "entrenched bureaucracy" (managers are always right and don't listen to the employees), could tinkering with Lean actually make things worse?

If we ignore the "respect for people" principle, waste elimination might be viewed as management pressuring the workers to work faster. If we're not fully involving people, we might get the wrong solutions and we might also alienate the very people who we need to have involved in Lean improvements.

What do you think? Have you seen superficial Lean efforts actually make your system worse as the result of "tinkering" and not adopting the Lean mindset, attitudes, and management system?

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Quotes from "Toyota Culture"

I've been making my way through the book Toyota Culture: The Heart and Soul of the Toyota Way at a regrettably slow pace. There's such good stuff in there... the chapter on "Servant Leadership" is outstanding. Page 320 includes a few statements/quotes that were "drilled into the minds and hearts of leaders at Toyota":

• "The team member is the expert."
• "Focus on the problem, not the person."
• "Mistakes are okay as long as people learn from them."
• "Take care of the people building the cars."
• "You work for your team members."

So simple, so brilliant.... so hard to adopt if you just "don't get it" or "can't get it."

Is it that difficult compared to implementing Lean methods like "kanban"? It sure seems like it... if statements like those above seem wrong or rub you the wrong way, can you be successful with Lean? A subtitle for the chapter could have been, "Get your ego out of the way", don't you think?

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Can Convis Turn Dana Around?

toledoblade.com -- Dana CEO, veteran of Toyota, hailed as mentor

Here's another nice article that gives an overview of the leadership style of Gary Convis, a long-time Toyota exec who is now CEO of parts maker Dana.

IF DANA Holding Corp.'s new chief executive officer has any words of wisdom that he tries to impart to those younger than his 65 years, Gary Convis tells them this: "Manage as if you have no power."

It was advice that the longtime Toyota Motor Corp. manufacturing executive received from his management mentor many years ago.

I could quote and comment until the cows come home -- but I'll just invite you to click on the article and take a look.

We'd all be better off if we had more leaders like Gary Convis.

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Trouble in a Fort Worth Hospital

JPS patients get shortchanged as cash surpluses keep growing

This linked article is a preview of what I'll be blogging about next. I'm trying an experiment in posting an article first... what comments do you have? Don't worry, I'm not totally outsourcing the blogging to the readers :-)

What a mess. Reading stuff like this will help you see the opportunities for Lean -- well, it's not just "Lean" but some good leadership. Maybe a mess like the hospital described in the article is beyond repair. It's embarrassing that this is the local county hospital in my area.

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Leadership versus Management

by Jamie Flinchbaugh, Lean Learning Center

For a long time, we have been saying that leadership is one of the top reasons that lean efforts fail. Many have begun to figure this out. Lean is more than changing a few systems and training a few people. But why does a support of improving leadership have to include a disdain for management. Management is like leadership - there is good, and there is bad. But it is different, and it is just as important as leadership.

There is a recent article in SME's Manufacturing Engineering Magazine called Leadership is Critical to Lean. This is of course true. But throughout it basically takes bad characteristics in organizations and calls it management. For example, management is described as:

• Often doesn't listen
• Stays detached
• Unconcerned
• Often insincere
• Knows it all
• In his/her office

Perhaps this is a description of bad management, but it is not management. Management is not as sexy as leadership. That's why writers don't like to write about it. But anyone who's ever been a manager knows there is more to it than authors think. I just happened to write about this in my latest Assembly Magazine Leading Lean column which you can read here.

Leadership is required to get things going. The quality and depth of leadership will determine how far and how fast you progress. But without management, it will be one step forward, one step backwards. Management is about accountability, daily problem solving, marshaling resources. Quality management is the backstop that sustains progress made. It's time to stop badmouthing management and instead focus on improvement management.

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A Podcast with Jamie Flinchbaugh

No, not my podcast (but I'm hoping to do another episode with Jamie soon).

This podcast is the first in a seriesdeveloped by Bosch Rexroth’s Linear Motion and Assembly Technologies group, each eight- to ten-minute lean manufacturing podcast episode will present guest experts and information to help manufacturers and OEMs understand and apply lean principles and practices in their businesses.

The first episode, with Jamie, can be found here. In the episode, called“Developing Front-line Supervisors to Succeed in a Lean Environment:"

Flinchbaugh examines the critical role front-line supervisors play in helping their companies successfully implement and sustain lean manufacturing practices. He also discusses guidelines for ensuring that supervisors are effectively trained and supported to fulfill their roles in lean operations. All too often, he says, front-line supervisors who are expected to perform in a lean environment are not equipped with the specific skills they need compared to those used by traditional supervisors.

Check it out. A lot of what Jamie says would also apply to hospitals. I like the phrase "taking super workers and making them supervisors." We can all do a better job of training new managers and supervisors about how to be leaders, with Lean or without.

Update: If you have iTunes, you can get to the podcast series via this link.

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A Lean Guy Reads the WSJ

A few short thoughts from today's WSJ:

'Headwind' Blows As Top Executives Navigate Trouble - WSJ.com

As I was reading the first article, above, about executives blaming "headwinds" and macroeconomic problems for business woes, I thought, "Sure, there are economic problems, but isn't that always a convenient excuse even when a business is being run badly?" Executives never give credit to macroeconomic conditions when times are good, do they?

The article then made the exact point:

"Weather terms appeal to economists and corporate executives because the market sometimes seems to behave like a force of nature. These days, Mr. Lakoff says, citing headwinds seems to be a way to duck blame for all kinds of business problems related to the subprime mortgage crisis, the credit crunch, even simple bad business decisions.

Some economists say the metaphorical wind only blows in one direction. Although executives are quick to blame headwinds for their woes, they are less likely to cite tailwinds for their good fortunes."

Interesting, eh?


Can Circuit City Survive Boss's Cure? - WSJ.com

This article caught my eye, since I remembered blogging about Circuit City last year when the company, which claimed "associates are our greatest asset," proved quite the opposite by wholesale firing those associates who earned too much.

This new WSJ article is laughable, as the CEO is still spooning out the same apparently meaningless tripe about valuing their employees. The CEO says tip #1 for managing a turnaround is "listening to your employees," that the best ideas come from "the bottom up." Well, after firing the "top" associates, all you were left with was the "bottom" and the cheaper replacements they hired.

I'm still not planning on rushing into a Circuit City store anytime soon, given their track record.

WSJ: How do store employees, who have been through multiple layoffs, fare in these changes?

Mr. Schoonover: We want engaged associates who have fun at work, bring a passion about the products, and enjoy serving customers. We've made a lot of changes in how we interact with our associates so that Circuit City could become the employer of choice.

Now that's just funny. Not "ha ha funny" like the WSJ's skeptical headline about whether the company can survive Schoonover or not. What do you think?

How do you fire the highest-paid associates and then expect a "fun" environment?

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Some Questions About Managers

Earlier this week, I asked some questions that managers and leaders should ask, prompted by an email I received through the blog.

I've been thinking about this and I've been trying to keep my "no blaming" hat on. Managers are part of a system -- therefore, we shouldn't blame individual managers, necessarily, for their "bad" behavior.

• Is the manager being held accountable for things that are out of their control?
  
  
• Is the manager being blamed by higher leaders?
  
  
• Has the manager had adequate training and mentoring about how to manage?
  
  
• What behavior is expected or rewarded by their managers?
  

Even if there is a "bad manager" involved, we should ask "why?" and probe to see if there is a root cause within the organization or the management system. What do you see in your organization? What other questions would you ask?

Back when I was at GM, we had a plant superintendent who was a legendary screamer. One day, he called me and another young IE into his office. He wasn't going to yell at us, but before talking, he called a unit manager on speaker phone. He yelled and cursed and screamed at the unit manager, putting on quite a show.

Since I was leaving soon for grad school (and didn't plan on coming back), I had the courage to ask the superintendent, "Why did you behave like that? What are we supposed to learn?"

He claimed, basically, to be part of a system. His boss yelled at him like that, so he was passing it on. He traced through the levels of screaming and cursing, basically tracing it all the way up to GM's board of directors.... therefore, he wasn't "choosing" to act that way, it was just the expectation and culture he had been a part of for over 30 years. I could sort of see his point, but it also seemed like a lame excuse... but his career might have stalled out earlier if he had tried to buck the system, right?

By the way, this was a guy who also didn't believe in Statistical Process Control.... that the line should keep running as long as the product wasn't "out of spec." And this was a plant that claimed to be managed under "The Deming Philosophy." Hardly.

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Some Questions for Managers

Some rhetorical questions to managers who say they want to "be Lean":

• Do you properly train new employees or do you just throw them into the job to figure it out themselves?
  
  
• Do you label those who speak up and identify problems (those asking for help) as trouble-makers?
  
  
• Have you provided tools and equipment that work properly and support the employees in their work?
  
  
• Do you know what problems your employees are facing? Have you seen why they aren't making their numbers or providing the proper level of service?
  
  
• Are you seen as a help or a hindrance by your employees? Are you seen by them at all?
  

If the answer to those questions is "yes" (and there are still workplaces where this is the case), is "Lean" really the first step you should take as an organization? If the leaders aren't willing to look in the mirror, asking "What will I do differently to help lead this organization?", is the "Lean" effort worthwhile?

For those who are wondering what prompts the questions.... an anonymous email.... from, of all places... a hospital. Not some backward knuckle-dragging 1970's era Taylorist factory... So much work to do in healthcare...

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Interesting NWLEAN Discussion

NWLEAN : Message: Why does Lean struggle to take hold in the U.S.?

I'm a member of the Yahoo Group called NWLEAN, where there's often some good discussion about Lean. The question was posed:

"Why does Lean struggle to take hold in the U.S.?"

I've often said that Lean doesn't fail or struggle.... or succeed.... people, leaders, or organizations struggle or succeed.

Let's not blame Lean. The question needs to be turned around... "Why do U.S. organizations struggle to fully utilize Lean thinking and Lean methods?"

Of course, I don't think those struggles are uniquely American either, although some of the underlying root causes might be different than other countries.

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LeanBlog Podcast #34 -- Chris Harris, Lean Workforces

LeanBlog Podcast #34 is a discussion with Chris Harris, from Harris Lean Systems, and co-author of the book Developing a Lean Workforce: A Guide for Human Resources, Plant Managers and Lean Coordinators. You can also purchase the book through Productivity Press.



If you enjoy this podcast, I hope you'll check out the rest of the series by visiting the LeanBlog podcast main page. Now that my book manuscript is done, I'm going to get back into regular podcasting, with episodes in the coming weeks featuring Norman Bodek, David Meier, and Jeffrey Liker. Let me know if you have questions for Dr. Liker, using the contact info at the bottom of this post.




MP3 File (Right Click to Save-As)

Keywords and Main Points, Episode #34

• Chris started working the assembly line at Toyota, then became a production supervisor at both Toyota and a different Tier 1 auto supplier.


• Focusing on the people is key, assuming most people want to do a good job.


• What's the proper role of a "Lean Coordinator"?
  
• What's the right role for a supervisor or a team leader? How do you make that transition?
  
• "The same reason Lean succeeds is the same reason it fails.... leadership."
  

If you have feedback on the podcast, or any questions for me or my guests, you can email me at leanpodcast@gmail.com or you can call and leave a voicemail by calling the "Lean Line" at (817) 776-LEAN (817-776-5326) or contact me via Skype id "mgraban". Please give your location and your first name. Any comments (email or voicemail) might be used in follow ups to the podcast.

Click here for the main LeanBlog Podcast page with all previous episodes.

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Would We Ever See This Today?

Even CEOs think CEOs are overpaid? - Yahoo! News

From a recent survey:

Sixty-four percent of top executives view CEO compensation as excessive, according to survey released on Tuesday.

It's something we've often talked about here, excessive CEO pay, particularly the outrageous sums paid to those who fail or get fired.

I stumbled across another article that mentioned George Romney, the father of Presidential candidate Mitt Romney, former governor of my home state (Michigan), and also former CEO of American Motors. In 1960, the elder Romney refused a $100,000 bonus:

Mr. Romney had previously told the company’s board that no executive needed to make more than $225,000 a year (about $1.4 million in today’s dollars), a spokesman for American Motors explained at the time, and the bonus would have put him above that threshold.

Here is the original NY Times story. Quite a contrast, isn't it? Has any executive in recent years taken a similar stand? I wouldn't count CEO's like Apple's Steve Jobs or Cisco's John Chambers who take $1 salaries, since they take their compensation in stock and perks.

It's keeping with the Toyota "respect for people" principle to not have such a huge gap between the pay of workers and top managers. Toyota's leaders are very "underpaid" (the CEO makes about $1 million) at least compared to the leaders of other large corporations.

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God Forbid You Actually Listen to the Bottom 98%

Management Leaders Turn Attention to Followers - WSJ.com

This article caught my eye, this idea that someone other than top executives might actually have some ideas.

In "Followership," a book being published this winter, Ms. Kellerman argues that a big organization's fate can be surprisingly dependent on how well it understands thousands of low-ranking employees, and makes them more effective. Entrepreneurs Ori Brafman and Rod Beckstrom took a similar perspective last year in their book, "The Starfish and the Spider," suggesting that lower-ranking employees, called catalysts, need to drive organizational change, instead of top bosses.

Considering that the Lean and Toyota Way philosophies have been, for so long, based on listening to the ideas of those who actually do the work, how is this considered innovative thought?? Isn't that the whole magic of the Toyota approach, helping make all employees effective and getting them pointed in the same direction? Is Toyota avoiding that "big companies die" dynamic better than most?

The Best Buy chain is trying, to their credit, to implement such ideas:

"Look at why big companies die," says Shari Ballard, Best Buy's executive vice president, retail channel. "They implode on themselves. They create all these systems and processes -- and then end up with a very small percentage of people who are supposed to solve complex problems, while the other 98% of people just execute. You can't come up with enough good ideas that way to keep growing."

When she visits Best Buy's electronics stores, Ms. Ballard says she asks managers: "What do you know about your customers that I couldn't possibly know?" The question encourages local initiatives that help Best Buy grow.

The idea that the "very small percentage" of top leaders are supposed to come up with the ideas, with the workers "just executing" -- that's Taylorism and MBA-centric thinking at its finest (yes, I have an MBA myself... sorry). What do you think about that question she asks her store managers. Would you phrase it that way? Seems like the right direction, but there's something about that phrasing I don't like... that "I couldn't possibly know" part could put people on the defensive (making them not want to show up the boss) depending on how the words are delivered and the organizational culture.

Anyway, interesting article and hopefully a trend that will grow -- actually listening to the people who are closer to the front lines. Shocking! Well... it's shocking, unless you've been studying Toyota and Lean.

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What a Delusional CEO Drives

What your CEO drives says a lot - USATODAY.com:

One thing I love about the Toyota Way is the humility and down-to-Earth nature of leaders, it's such a contrast to the arrogance you so often see in other circles. USA Today had an interesting article about what CEO's drive and the message it sends. Some drive very practical cars to send a frugal message, others are flashy and use that to push their employees (including one who, somewhat perversely, wants employees to be in debt so they'll be motivated to sell more -- yikes).

The real laugher was this... I can only imagine that this guy is like:

"'My employees like to see me driving a nice car,' says Larry Gaynor, CEO of Nailco Group, a beauty products company, who drives a white $100,000 Porsche 911 Carrera S Cabriolet. 'It gives them a feeling the company is doing well.'

Perhaps, Gaynor says, there are other reasons employees notice what he drives. 'For years I parked at whatever spot was open,' he says. 'A couple of years ago we redid the parking lot, and some of my employees told me that I should have a reserved space.' Now, everyone now knows if he is at work, or away."

Yeah, I'm sure the employees feel so warm and fuzzy that the CEO is being paid so well. And he has himself convinced about the reserved space. Would you guess the employees are scared of him if they need to be able to tell if he's there or not? Again, all speculation, but sounds like a potentially dysfunctional workplace, don't you think?

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Quaid Case Update: Whose Responsibility is Standardized Work?

If you're a regular reader, you might recall the Cedar-Sinai medical error that harmed Dennis Quad's twins (and others).

Quaid and his wife are now suing the maker of the drug, Baxter, claiming the company is negligent for not designing packaging with good visual distinctions between the two doses (photo there on the linked TMZ.com page).

This week, Baxter announced an initiative to redesign the packaging of their "high risk" medications.

Considering this problem has happened before, I'm sure that effort isn't just a direct response to the Cedar-Sinai incident. It sounds like Baxter tried to get some "voice of the customer" input:

Baxter conducted multiple interviews with more than 100 pharmacists, physicians and nurses to identify areas for improvement . The feedback received from health care professionals guided the design of the new vial packaging.

In research conducted after the three-phase development program, clinicians indicated that the new packaging design enhancements addressed the current clinical needs for safer injectable drug administration and could help reduce medication errors.

“Health care professionals played a vital role in the design of the new label and we look forward to their continued input to gain key insights that will help in the development of future design enhancements, ” said Bonderud.

Baxter had already done some redesign, but Cedar-Sinai may have tried to save a few bucks by using up the old medication (in the old packaging) first. Normally "FIFO" would be a good thing, but not if the old product leads to a greater patient safety risk. In hindsight, would have been cheaper to throw the old stuff out, right?

I'm also not impressed that Cedar-Sinai leadership is apparently throwing their employees under the bus. In a statement, they said:

The medical center's investigation found that preventable errors made by pharmacy and nursing staff caused the wrong concentration of heparin to be used.

A pharmacy technician failed to follow hospital policy of having another pharmacy technician verify the medication and concentration prior to removing it from main pharmacy inventory. As a result, the technician mistakenly retrieved a higher concentration of heparin (10,000 units per milliliter) instead of the lower-concentration heparin (10 units per milliliter) used for flushing IV catheters.

The higher concentration heparin was delivered to the satellite pharmacy that serves the pediatrics unit. A second pharmacy technician, working in the satellite pharmacy, did not verify the concentration of the delivery from the main pharmacy, as required by hospital policy.

As a result, the higher-concentration heparin was placed in a location in the pediatrics unit where the lower-concentration heparin is kept. The nurses who subsequently administered the heparin to the patients also did not follow hospital policy of verifying the correct medication and dose prior to flushing the intravenous site.

The error was identified later that day by Cedars-Sinai staff, who immediately performed blood tests on the patients to measure blood clotting function. In one of the three patients, the clotting tests returned quickly to normal. The other two patients were given protamine sulfate, a drug that reverses the effects of heparin and helps restore blood clotting function to normal. Additional medical tests and clinical evaluation conducted on the two patients found no adverse effects from the heparin or from the temporary abnormal clotting function.

"Although this was a rare event, and attributable to human error, it is also an important opportunity for the entire institution to explore any and all ways we can further improve medication safety," said Michael L. Langberg, M.D., chief medical officer at Cedars-Sinai Medical Center.

"On behalf of the medical center, I extend my deepest apologies to the families who were affected by this situation, and we will continue to work with them on any concerns or questions they may have. This was a preventable error, involving a failure to follow our standard policies and procedures, and there is no excuse for that to occur at Cedars-Sinai," Langberg said.

Whose responsibility is it for the Standardized Work to be followed? Doesn't management have a responsibility to be proactively checking and looking to see if policies and procedures are being followed? It's not enough to wait and react when an incident occurs. I'd guess those same policy violations were happening every day and it finally caught up to them. Are employees responsible for following processes? Sure, but it's also management's responsibility to manage the process and the people. Does Toyota say, "well, our policy says people don't build defective vehicles"? Of course not.

Does management taking responsibility mean that we constantly hound and watch employees? No, but we have a responsibility to check to see if there are violations of policies BEFORE an injury or death occurs. Proper training and re-training should happen BEFORE problems occur. The employees directly involved in the Quaid incident are suspended. What about the managers and leaders?

To be fair, Cedar-Sinai is making a number of systemic changes (including moving from using heparin to saline, which is much safer, they say). But, they've also added MORE double checks (adding more of a method, relying on inspection and "be careful," that didn't work 100%).

I hope other hospitals, where the same risk factors exists, will be more proactive. We need to make "preventable" errors into "prevented" errors.

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The New Style CEO?

C.E.O. Evolution Phase 3 - New York Times

In this quote:

Mr. [X] “is disarmingly unpretentious,” he added. “...he towers over other C.E.O.’s when it comes to putting in people stronger than himself or his ability to talk about setbacks.”

Is this Toyota's Katsuaki Watanabe? No, it's Proctor & Gamble's A.G. Lafley, who the NY Times (via Warren Bennis and Jeffrey Sonnenfeld) claims is the prototype for the new style CEO. If that's really true, seems like a good trend. They say we're moving away from the old CEO type - the empire builder with an "outsized ego" (they pointed at Jack Welch) who is too insecure to have strong people around or under them (they pointed at Stan O'Neal).

The new CEO has to be more than just smart, they also have to be leaders and to build teams. Imagine that! They also point to Boeing's W. James McNerney Jr. as another prototype of this type of leader, along with Anne Mulcahy, chief executive of Xerox.

“They’ve got to have not just the cognitive ability to run a major firm, which Stan O’Neal definitely had, but the ability to make people feel like they’re working together,” Mr. Bennis said.

I hope Bennis meant that they wouldn't just "feel" like they were working together, but that teamwork was actually happening.

“Both felt the need to make sure the top hundred people know that they’re in this together, that their fates are correlated,” Mr. Bennis says. “That’s what it will take to succeed in this century.”

Just the top hundred? That's a start, I guess, although it's a typically execu-centric view of the world. How about getting the whole company to think their fates are correlated? Now that would be amazing leadership, don't you think?

So what do you think? Will we see the end of the top-down, command-and-control CEO who has to have all the answers? Are these researchers studying the leadership styles of Toyota, correlating that with their amazing financial performance? I'm anxious to read Jeff Liker's new book, Toyota Culture: The Heart and Soul of the Toyota Way. Another outstanding book on the subject, maybe at more of a tactical level is Creating a Lean Culture: Tools to Sustain Lean Conversions by David Mann.

Thanks to the person who ordered 10 copies through my amazon link!

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Gary Convis on Lean Leadership

Role of Management in a Lean Manufacturing Environment

If you want to learn about the Toyota style of leading people, one of the best sources is Gary Convis. Here is a link to a column written directly by him.

For anyone who is struggling with a "Lean tools" implementation attempt, but sure to check this out. I always find it inspiring to read his approach or to hear him talk about it. Gary is also featured pretty prominently in the David Magee book, How Toyota Became #1: Leadership Lessons from the World's Greatest Car Company.

A highlight from the Convis piece:

"In my opinion, the key to the successful implementation of TPS at NUMMI, and TMMK, and at the other Toyota plants in North America, has been the total commitment on the part of everyone to make it work. By that I mean, all levels of the organization, from team members to the senior managers, have to be aware of the fundamentals of TPS and have to make their best efforts to practice and improve them day-by-day."

While Lean requires employee engagement and involvement, Lean is not something that can be delegated completely. Leadership needs to understand TPS, not just front-line supervisors. As I've said before, Lean requires commitment and dedication. "Lean" does not succeed or fail. Leaders succeed or leaders fail. Sometimes we fail by giving up too quickly or by not learning more beyond an initial Lean attempt (which might have just been an attempt at a single tool, like 5S or kanban).

He continues to explain the ties between philosophy, tools, and management approaches:

"TPS is an interlocking set of three underlying elements: the philosophical underpinnings, the managerial culture and the technical tools. The philosophical underpinnings include a joint shop-floor, customer-first focus, an emphasis on people first, a commitment to continuous improvement or kaizen, and a belief that harmony with the environment is of critical importance. The managerial culture for TPS is rooted in several factors, including developing and sustaining a sense of trust, a commitment to involving those affected by first, teamwork, equal and fair treatment for all, and finally, fact-based decision making and long-term thinking."

He also explains the wonderful phrase "to lead the organization as if I had no power."

Great reading, the whole thing. A great "intro to Lean" if you need something to send to your senior management, maybe. The headline really could read "Role of Management in ANY Lean Environment".