Produced in partnership with the Healthcare Value Network, episode #119 is a discussion with Dean Gruner, MD, the president & CEO of ThedaCare. Here, we talk about Strategy Deployment as a Lean management system and how it fits into their ongoing management and improvement efforts in their health system.
To learn more about strategy deployment, visit YouTube for a free preview clip of a new educational DVD produced by the ThedaCare Center for Healthcare Value. You will also find a link to a free white paper about strategy deployment at ThedaCare, Group Health, and St. Boniface General Hospital.
For a link to this episode, refer people to www.leanblog.org/119.
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Mark Graban: Hi. This is Mark Graban. Welcome to Episode 119 of the podcast for May 31st, 2011. Today's podcast is produced in partnership with the Healthcare Value Network. We're very happy to have Dr. Dean Gruner as our guest. He's the President and CEO of ThedaCare, considered by many to be a leading Lean healthcare organization in Wisconsin.
We're going to be talking about Strategy Deployment at ThedaCare. This episode's a bit of a teaser for a DVD that has come out recently from the ThedaCare Center for Healthcare Value, called Thinking Lean at ThedaCare, Strategy Deployment.
As always, I want to thank you for listening. Dean, I want to thank you for taking the time to do a podcast with us today.
Dean Gruner: Thanks, Mark. Always good to talk to you.
Mark: I wonder if you can start first… give a basic introduction about yourself, and your role at ThedaCare for the listeners.
Dean: Sure. My name is Dean Gruner. I'm a Family Physician by background. I serve as the President and CEO of ThedaCare, and have done so since April of 2008.
Mark: We're talking today about Strategy Deployment. I'm guessing listeners may know in general, the use of Lean within ThedaCare and the ThedaCare Improvement System, but can you start off with maybe a high level overview of what Strategy Deployment is?
Dean: Strategy Deployment to us is trying to align the work throughout the organization, from executive levels all the way down to the front line people, and also trying to make clear what are the breakthrough initiatives to the highest priorities in an organization in a certain period of time.
Mark: Can you tell us when and why ThedaCare started to incorporate Strategy Deployment into the management system? Why you thought this is something that might be helpful?
Dean: We sort of stumbled upon it over time. Our earliest work, which really was not Strategy Deployment, but it's trying on this alignment concept, was when we were trying to develop our Improvement Centers or our Tracking Centers, what people call our Production Control Boards.
We wanted to create a standard about the columns, or the lanes if you will, for that work, so we started to do that. We had a lot of conversation about what those lanes should be, and we eventually said that we're going to have five of them, and they'd be Safety, Quality, Customer, People, and Financial Stewardship.
That was probably 2006, about five years ago, when we tried to standardize that. A year-and-a-half later, probably it was winter of 2007-08, we started to use A3s, which we refer to as a PDSA, as our method for selecting our major breakthrough initiatives.
As we did that, we then had to try to talk about what our True North metrics would be, and how were they going to measure our success in our strategy?
It became a very iterative process where we evolved into taking the work at our breakthrough initiatives for our SD work, and communicating that through the use of all of our Improvement Centers throughout the organization, and combining the visuals of that strategic work, of our SD work, with the frontline work of the columns that people have on their Tracking Centers.
The combination of those two things, meeting in the middle, not bad. People in our front line can visually see every day where they track their work. They can see how our big strategy issues connect to our True North metrics, and connect to their work on the front line.
Mark: You talk about alignment. That's certainly a key theme with Strategy Deployment. You talk about the need to have more alignment. If it's OK, can we talk a little bit maybe about some of what the current state had been, when you were starting Strategy Deployment?
Why was it you thought there was a need for better alignment, or what an example might be of an instance where the alignment wasn't as good as you would want it to be?
Dean: The way I would describe the gap that exists today, but it's smaller today than say three to five years ago. Three to five years ago, on the Executive team, we thought we did a great job of communicating our strategy. We'd go out and we talked to people using PowerPoint presentations, conversations.
We thought we were going to do a great job. If you ask people on the front line, to what extent do they understand the strategy of the organization, they would rate that quite low in Employee Opinion Surveys.
On the one hand, we're thinking we're doing a great job of communicating it, and we're getting feedback from employees that they don't really understand what the heck we're trying to do.
Then, we're further looking at the employee. If we're going to have to move faster as an organization, it's really important that people throughout the organization, all know what we're trying to do. We have this cognitive dissonance that we're thinking we're doing a great job.
First time that's ever happened in an organization, right, that somebody thinks they're doing a great job, but getting feedback that there's a big gap. What we've done with creating the visuals, and trying to pull that into people's daily work is so that people understand more what we're trying to do. Then you have conversations about it like, “Why are we trying to do this?” It's helped us a great deal from that standpoint.
Mark: I think it's fair to say that's not a unique problem to your organization. I have a friend of mine, for example. He works in an Emergency Department at a hospital in another state. We were chatting the other day, and we talked about strategy. His first comment was, “My colleagues and I have no idea what the strategy is.”
It seems like that communication is an important piece for getting alignment. Can we talk a little bit more about the idea of measurement? You mentioned Tracking Centers. Can you describe briefly what that looks like for you and your senior leadership team?
Dean: We track a number of things. We try to cascade from our True North metrics, which we use four categories. We have a triangle, as we refer to it, so people here talk about the triangle. The top is Safety and Quality, the center is the Customer, lower left is People, and lower right is Financial Stewardship.
When we take those four parts of the triangle, and we take them down into the areas that each operating would be measuring, it flows right nicely into Safety, Quality, Customer, People, Financial Stewardship.
At a high level, if now where we are trying to track productivity, and our Financial Stewardship, and we're trying to measure our operating margin, and our productivity, as a too big system-wide rollup measures, then at an individual department level, people would say, “What are we measuring?
Are we measuring net income, or operating income?” Probably not, depending on the department, but they would be measuring things like flat expenses per units of service, and productivity on their local level, so they can see how it connects to the big picture.
If you're measuring people measures, so we measure engagement of our people, and we have that as a system-wide measure, and we also measure their health, what we call our Health scores, our Health Risk Assessment Scores, we know as a system we're measuring the health, but how's the health in their operating unit?
What is the health of their employees? What's their OSHA recordable injury rates? People can see the cascade of that. They can look at that and say, “What are we going to measure here for safety? What's our part of improving safety, and preventable mortality, which is a True North metric, and medication there?” What is that?
What we find is when people ask those questions then; they're self-aligning with the True North metrics. “Geez, I can see what the system is. What is our portion in this operating unit, in this business unit? What's our contribution to that?”
In some areas they've done a fabulous job. In some areas we've got more work to do, but it starts those conversations about how their work holds up to the organization's overall strategy.
Mark: It starts with communication that strategy, and then having measures that are aligned and meaningful. Then the other piece is aligning people's improvement ideas to those measures, to that strategy. Can you talk a little bit about that process?
Dean: That process is very much frontline generated. We have a process that we've been doing better at over time, where employees identify improvement opportunities by specifying what is the problem. Why do they think it's happened? What are the potential solutions?
Then it connects to True North impacts, so they check for this is the Safety, Quality, Customer, People, or Financial Stewardship issue or multiple ones. The process and the reviews are, as people generate those ideas in their huddles, they take those ideas, and they use a PICK chart to prioritize them, because we can't put all of it in play right away.
They prioritize them in a PICK chart by difficulty and by impact. Then after they do that, they decide how many of these they can work on at once. When they've got some additional capacity to work on a new idea, they go over to their PICK chart and say, “Based on the impact it has, and difficulty, and the area that it will address, which of these are we going to put into play next?” and they put it into play.
Depending on how complicated that is, it may be something that's just a few hours of work to put in place, or it may require more thought and a complete A3 or PDSA, or may require even a whole week work of a rapid improvement event. It helps people again when they have to go through this improvement opportunity.
They write it down, and they have to circle it, which True North impact it is. It connects it again with the overall strategy of the organization.
Mark: Thanks for describing that for us. Maybe a final question here to help wrap up. Now that you're a few years into this process, and you described it as an iterative process over time, can you describe at a high level what some of the benefits are to the organization that you've seen from doing Strategy Deployment, and from getting better at doing strategy development perhaps, over time?
Dean: When you're inside the organization, sometimes you don't appreciate the benefits that much. You're so close to it you don't see the forest for the trees sometimes. It's when people come and visit us, which they do all the time.
We consistently get everybody telling us that they can't believe how everybody on the front line describes what our strategy is, and how everybody understands how their work relates to the big picture.
I have come to take that for granted, like “Of course. That's the way it's supposed to work, right?” That's not the way it usually works. That said, we still have many opportunities for improvement, so this is not like we do this universally well throughout our whole organization of close to 6,000 employees. We're getting closer.
The system CEO, I can't go out and meet with 6,000 people all the time, and even if I do, I know that the amount of information they will remember of what our conversation is, is pretty small. It's in the daily work of them at an Improvement Center where they're looking at ideas and problems, and they're problem solving, where you really reinforce that.
I think John Shook's the one that, and probably many people have said this, that it's easier to act your way into a new way of thinking, than to think your way into a new way of acting. This gets people acting in their regular huddles using the process, and reinforce, so that it gets them to act into a new way of thinking in concert with what the organization's goals are.
Mark: Dean, I want to thank you for taking time to give an overview into Strategy Deployment, and sharing some of the great work you're doing there at ThedaCare.
Dean: Absolutely. It's always fun to talk to you, Mark. If this can help other organizations improve their performance and their Strategy Deployment, always willing to do that.
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