Dr. Jack Billi on Lean Thinking, A3 Problem Solving, and Engaging Physicians

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Episode #110 is a chat with Dr. Jack Billi from the University of Michigan Health System and Medical School.

Here, we talk about their lean work and how Dr. Billi works with physicians to engage them in lean, tying lean problem solving methods, including the A3 approach, to the scientific method and medical thinking. Dr. Billi talks about the right approach to the lean concept of “standardized work” in a way that works for medicine and complex patient situations.

More about Dr. Billi,  Associate Dean for Clinical Affairs, Medical School and Associate Vice President, Medical Affairs:

Dr. Billi is Professor of Internal Medicine and Medical Education. He leads the Michigan Quality System, the University of Michigan Health System's unified approach to improve quality, safety, efficiency, appropriateness and service using lean tools and philosophy. Dr. Billi's research and leadership interests are in health services delivery and the use of community consortia for quality improvement. He is active on statewide and regional groups affecting quality of care, pay-for-performance and public reporting. He chairs the Michigan State Medical Society's Committee on Quality, Efficiency and Economics and the Essential Benefit Design Work Group and is a member of MSMS's Board of Directors. Dr. Billi co-chairs the Medical Director Committee for the Michigan Quality Improvement Consortium which develops and disseminates evidence-based practice guidelines used by Blue Cross Blue Shield of Michigan and 15 other health plans representing over six million members.

To point others to this episode, use the simple URL:  www.leanblog.org/110.

For earlier episodes, visit the  main Podcast page, which includes information on how to subscribe via RSS or via Apple Podcasts.

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) 372-5682 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.

Transcript:

Mark Graban: Hi, this is Mark Graban. Welcome to episode 110 of the Lean Blog podcast for January 27, 2011. Our guest today is Dr. Jack Billi, Associate Dean for Clinical Affairs at the University of Michigan Medical School and Associate Vice President for Medical Affairs at the University of Michigan Health System. Dr. Billi is a Professor of Internal Medicine and Medical Education and he leads the Michigan Quality System, the University of Michigan Health System's unified approach to improve quality, safety, efficiency, appropriateness and service using Lean tools and philosophy.

In our podcast discussion today, Dr. Billi is going to talk about his work at the University of Michigan Health System and especially about how that ties in to working with physicians and engaging them with the lean problem-solving process. Well, Jack, I want to thank you for taking time out of your day and your busy schedule to talk today. Thanks for joining us.

Dr. Jack Billi: I'm really delighted to be here. I've learned a lot through working with the Healthcare Value Leaders Network and the work that you've done. So delighted to chat.

Mark Graban: Well, thanks. It's a pleasure to have you. I was wondering if you could start by introducing yourself for the listeners, who you are and what your roles are there at the university.

Dr. Jack Billi: Sure. My name is Jack Billi. I'm a general internist. I've been at the university for 33 years. I've spent a lot of that time as associate dean for clinical affairs in the medical school, and I also have a role in the health system to complement that. But my most important work for the last five years has been as the what might be called the chief engineer or the senior deployment leader for the Lean Transformation for the University of Michigan Health System.

Mark Graban: I'm curious, maybe also in terms of introductions, from your career as a physician and a leader in the university and the health system, what was your first exposure to Lean? You're there in Michigan, you have the auto industry, you've got a lot of well-known lean people within the university. Where did your first exposure come from and maybe share, if you can, some of your initial reactions to Lean from your medical background?

Dr. Jack Billi: Well, I'd been involved in problem-solving in various administrative roles for the central administration of the health system for many years, but had no formal model. It was probably about seven years ago that Gary Kaplan, the CEO of Virginia Mason, who's an alum of the University of Michigan, was invited in to give a talk about the use of lean thinking at Virginia Mason. And that really captivated me. I went to dinner with him that night and we walked across the street to Borders Bookstore and I bought a copy of Lean Thinking by Jim Womack and really have never looked back since that time. It made so much sense to me to try and bring a much more comprehensive model to our problem-solving. And instead of having people all using their own sort of homegrown, intuitive models, some really not very robust for solving problems, it seemed like it made a lot of sense for us to pick a consistent problem-solving model across the health system. So we've been working on that pretty intently for the last five years.

Mark Graban: I guess it's not surprising you had mentioned Gary Kaplan's name. A previous guest we talked to, Michel Tétreault, answering that question also brought up Gary Kaplan as an initial introduction to Lean. Do you find it helpful in general with your colleagues and people you work with? Is it helpful to hear it coming from another healthcare leader?

Dr. Jack Billi: I think that it actually takes both influences to really make the point with individuals and organizations. We've learned a lot from folks like John Toussaint, Gary Kaplan and folks at some of the other leading healthcare organizations that have adopted Lean in the US, the UK and Australia. We've learned a ton from those healthcare applications. But we've also learned a lot from folks from industry, from manufacturing, banking and other industries. In fact, GM is headquartered in Michigan, and has adopted a lot of lean thinking in what they call the Global Manufacturing System, or GMS. They gave us a leg up by helping us facilitate the first six learning projects we did.

So if you ask healthcare organizations around the country, where is their help coming from? A lot of time it's from a manufacturer. John Toussaint talks about the snowblower manufacturer down the road in Wisconsin. Gary Kaplan and Virginia Mason in Seattle had Boeing and uses Genie Enterprises now. So there's a lot of learning that crosses industry. It's interesting. There's some doctors and nurses who seem to only be able to hear it when it comes from another healthcare person. They have trouble translating the lessons in from other industries. And there's others who are really liberated in their thinking by seeing that these models work across a lot of different industries, having the frontline workers find and fix root causes, and they enjoy the challenge of translating it into healthcare. That's what really fascinates me. And there are folks that are also turned on by that and they learn a lot from other industries, not just healthcare.

Mark Graban: So in the course of your leading and teaching and chief engineering of these efforts, what are some of the key translation points or parallels that you draw, speaking specifically to physicians who maybe don't feel that natural affinity or curiosity to another industry? How do you translate it or relate it to physicians that are asking questions about what is transferable from a business or a manufacturing system?

Dr. Jack Billi: Well, it's really interesting. Steven Spear, who's now at MIT and IHI, when asked the question, “Yeah, but you know, people aren't cars,” would answer, “Yeah, cars are much more complicated,” and then go into a long discourse on all of the explosives and plastic bags packed in your steering column. But without going there, I generally don't try and convince people that designing and building an automobile might actually be more difficult than some of the things you do in healthcare. So when I'm talking with clinicians, especially doctors, what I try and do is make the analogy between the kind of problem-solving you do using lean thinking and delivering great patient care. The analogy is almost perfect.

When a doctor is confronted with a patient with a complex medical problem, the first thing they do is go and see the patient, exactly the same as the concept of Gemba, to go and see the problem with your own eyes at the real place where it occurs. And they take a history and physical in a very systematic fashion, not just willy-nilly. And that's exactly the same thing we try and do with lean thinking, a really systematic investigation of the way the work is done, things like value stream mapping and root cause analysis. And then they actually distill their thinking in a systematic problem-solving format that we call a history and physical impression and plans. And I make the analogy that that's quite similar to A3 problem-solving where you're talking about why the problem's important, how it is now, what the goal would be, what the root causes would be. In the same way that in the clinical example, when we face a difficult patient, we don't just treat the symptoms, we try and understand the real cause and get at some diagnosis and treatment steps that will try and address the underlying problem with the physiology. The same way in lean thinking we try not to jump to solutions, we want to try and understand deeper root causes.

So the analogy just keeps going along. We present our information in a systemized format. In a history and physical, we don't just blab on about a patient, we have a very standardized way of presenting patients. Likewise, we have a standardized way in lean thinking using an A3 format for presenting our thinking so we can build consensus on problems. And with patients, we run tests and try treatments knowing that they may not work. We arrange follow up to see what happens. So I think the analogy is really quite complete. So all of our clinicians, what I tell them is lean thinking is just like taking a good history and physical on a problem, trying to figure out what's wrong, and then trying some tests and treatment and then doing some follow-up. It's the kind of thing they do naturally in the clinical environment. I just want them to transfer that same analytic skill and rigor to the problems that they confront every day in the way they're getting their work done. Problems that jeopardize patient safety or make work more efficient, that frustrate the workers. Those problems can be approached with exactly the same rigor.

Mark Graban: Yeah. So when you use the word standardized, I was about to ask you how that might tie into the lean framework of standardized work. The idea sometimes you hear talk about complexity, people will say, “Well, every patient is different.” But what I hear you describing is that that doesn't mean you reinvent the process for what you do when that unique patient is there in front of you. I mean, how do you see the role? Are you able to show how standardization doesn't necessarily have to be overly constraining?

Dr. Jack Billi: Right. Well, the key to standardizing, Mark, is which things to make standard work around and to try to standardize. So just as you said, we're not trying to turn this into cookbook medicine or cookbook problem-solving. But no matter how complex a patient, we still start with taking a history, trying to decide what the chief complaint is, what the main problem is, what's the thing that's most likely to harm this patient in the shortest period of time, how can we intervene on that most quickly? And so there's parts of medicine that are really very standardized. The way we collect our information, the fact that we try not to jump to treatments before we've tried to understand what's causing various problems, and implementing all our steps with patients, we do as experiments, if you will. Sometimes they're actually formal science experiments. That is, we're conducting research, but a lot of the time we're giving a person, we're doubling the diuretic. We want to see if we have the expected result. So that same approach, which is using the scientific method, we try to apply that to patient care. And so I try to help clinicians see they're going to use that same standardized approach to trying to solve the problems they face in work every day.

Some of our folks at the University of Michigan and many other healthcare entities across the country are also engaged in research and the interesting thing is when they're in the laboratory or they're conducting a clinical trial with a patient, when they're doing real research, they know the importance of standardizing everything so that when we vary something, we have a reasonable assurance that the outcome is related to what we've varied rather than to just vagaries in the conditions. And so we try to use that same rigor when we're trying to improve our daily work, try to standardize whatever we can so that when we vary something and get a different outcome, we actually can draw some conclusion, can learn from that, and that informs the next experiment that we'll run. So we found physicians really can gravitate to that.

It's not the challenge of applying this method that I find most problematic for physicians. It's actually the fact that many of them consider themselves kind of like victims of the process. They don't believe they can change the process. They see how it could be done better. But they often fall into the trap of saying, well, it's “the five who's” rather than the five whys. “Those clerks don't understand how I'm doing my work. They want me to do this differently.” It's a lot of classic things like you'd find in manufacturing where people have prejudices and biases about the people who are upstream and downstream from them. They don't really know how the work is done. And if we can, when we get them involved in value stream mapping or in root cause analysis, you can see the scales falling away from their eyes. I can't tell you how many times we've had a value stream map or an A3 with docs involved. And they look at the mess on the wall when they're doing a map and they say, “I can't believe what a mess this is. I can't believe a patient ever makes it through. Who designed this process?” And of course no one designed it. It's just the accretion of responses to regulatory requests and third-party billing and some other customer service initiative. And before you know it, you've got an incredibly complex process to get work done. And then once they have that “aha” moment and they realize how complex and unnecessarily error-prone the process is, then you start to see them become empowered and motivated. And instead of being victims of the process, they try to take it on and say, “Well, why can't we do that? What about this? What about that?”

Mark Graban: Well, and what you're describing there sounds like a translation of principles and problem-solving processes as opposed to just an application of lean tools. I would presume that those principles, tapping into the physician thought process, the scientific process you refer to, is helpful getting them involved in looking at the process. And I was wondering maybe if you could share some examples of some of that process improvement or some of the other work that's been done there in the University of Michigan health system. Because I know this has been more than just an academic exercise, if you will.

Dr. Jack Billi: And it's really interesting. We all want to use lean thinking as a fundamental business strategy, a holistic model of approaching our work. What is the purpose? Who are the customers and what problems do they have? How can we solve them completely? What are the processes and how do they work, and who are the people to systematically analyze? But of course, everyone focuses on the tools. We all want to make sure that lean is more than just the application of simple tools, because you only get so far using the tools. So on the one hand, first, we actually train people in all the tools. If we're doing a program, we'll actually train them about the tools, because until they understand the tools, it's very hard for them to see how this fits together as a holistic problem-solving model. And the tools are really powerful. On the other hand, if they just stop with the tools, then they can only go so far. So as John Shook says, “No matter where you start, it's the wrong place.” You'd wish you'd done it a little bit differently.

But in the places that we've applied this within the University of Michigan health system, we've worked virtually soup to nuts. We have projects in our cardiovascular center. We had had a worsening of our length of stay in cardiac surgery. And we tracked down some of the root causes were related to problems with handoffs coming out of the OR. So we made standard work around the handoffs. The people themselves, the anesthesiologist, the nurse receiving the patient in the ICU, they developed a standardized handoff process with a form. They have a specific handoff exchange that can't be interrupted. And as a result of that and some other interventions that arose out of that, we were able to cut two days off the simple cardiac surgery length of stay. We did a similar project in our neuro ICU where our neurosurgery cases were being managed. And between the neuro ICU and the floor, we were able to cut a little more than half a day length of stay by the work. The way it was done before was really quite random. And by making standard work and the way handoffs were done, the way the floor nurses interacted with the neurosurgeons and the neurosurgery residents, standardizing those interactions really worked wonders.

But if you look at the last five years, we've spent a lot of time in what we would call point improvements. So we were able to get all the cases to start in our children's OR on time. For the first time ever, we had 100% first case start time. And what happened that day? All the cases backed up in recovery because we weren't thinking about flow. So over the last year, we spent a lot of time trying to move from point improvement to flow improvement and to system improvement. We've commissioned a group of what we call major patient journey value streams and have conveners working on those at the same time. Over the last five years, we spent a lot of our time in the people development model, but mostly focused on individual learning. And so this last year we've started a bunch of experiments in local implementation teams where we'll work with 30 or 50 workers in a particular clinic or a particular area, helping them all implement, create standard work for themselves, implement the standard work, and then using visual controls that they keep themselves, they and their manager culling what are the most common problems occurring today, visually presenting them, Paretoing them, and then solving them. So we're trying to move out of the basement of these two buildings, a people development building where we were stuck in primarily point learning, that is individual learning, and the process improvement building. We were stuck in point improvements, trying to move up to the second and third floor in each of those buildings.

Mark Graban: And that seems like quite a natural evolution that other organizations have gone through over time, I think. Well, I want to thank you, Dr. Jack Billi from University of Michigan. Time has passed quickly here with the podcast. I want to thank you for sharing some of your thoughts and perspectives of your evolution with Lean, both personally and at the university. Do you have any final thoughts for the listeners that you might want to share as a wrap up?

Dr. Jack Billi: Well, we have learned an enormous amount. We still have a tremendous amount to learn, but our goal, our motto for the Michigan Quality System is “20,000 problem solvers.” That's how many people we have working and training at the University of Michigan. So not the small cadre of the Kaizen promotion office, but rather every person in the organization. We found our frontline workers and our trainees are an enormous resource for that kind of improvement. So we're on the journey. We're learning along with many of the other organizations in the country. We're glad to share some of what we've tried and what we've learned, and we look forward to learning more from our many colleagues. Thanks very much, Mark. I really enjoyed talking to you.

Mark Graban: Okay, thank you.

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