Mark's Note: Today's post is by a new guest contributor, Tom Gormley. I first met Tom back in 2009 or 2010 when my wife and I were in Boston for the year. He was in the process of switching into healthcare and he has had a few roles with different health systems since then. You can read his short bio here or a full bio as a PDF.
“I kind of know what I see.” — Tom Brady
In lean circles we often say that lean principles and thinking are applicable in just about every industry, right? Even in football? Why not?
In the WEEI article above, TB12, the New England Patriots' four-time Super Bowl winning quarterback, responds to a reporter's questions about the use of tablet PCs in in-game strategy (probably in response to Belichick's negative comments earlier in the week on the same topic). Interestingly, there is a lot of lean thinking in TB12's responses and apparently in his approach to winning games. Read on…
Value and Waste
Consider the lean definition of “value”, so central to lean thinking – value is defined by the customer; what they're willing to pay for; activity that transforms the product or service bringing it closer to the customer's desire. Steps in a process that don't meet these criteria are non-value, or waste. Value flows to the customer when each step and the hand-offs between them meet these criteria with defects or delays.
Here's Brady's take on value and waste in the football context:
“There's nothing good that happens when the ball is my hands. I've got to get the ball to somebody that can actually do something with it, so that's part of it for me is identifying who should get it, how quickly they should get it, and then getting the ball out of my hands and into the hands of the receivers or the running backs so they can actually make some yards.”
Brady, the team's and multiple MVP award winner, sees his time holding the ball as waste, and defines value as yards gained. Moving the product closer to the desired end result – points via touchdown or field goal, and winning games. As a fan, this is what I value, so I'd say Brady has it right. I enjoy the excitement and entertainment when Brady has the ball, but I like to see the Pats drive down the field, score, and ultimately win games. Brady understands his part in the process – holding the ball is waste because value isn't flowing until he gets it to another player who can make yards. Brady practices ways to minimize that waste. Viewing his role in this way also requires humility, and humble leadership rubs off on teammates, encouraging a common focus on value to the customer.
How do we define value in healthcare, and how do we ensure it flows with minimal waste to the customer – our patients? Do staff practice ways to enable flow, and do our stars, whether nurses or physicians or others, humbly work to keep the value flowing? Unfortunately, most healthcare processes still run in silos, resulting in significant waiting, error-prone handoffs, and re-work. Consider patient registration – it's required, but not the value patients are seeking. Does the process minimize the patient's time-to-provider, or does it send them to a waiting room? How about gathering supplies, forms, or instruments for an exam or procedure? Also waste, by the lean definition, although they're needed for the value-adding work to be done. Or a provider taking her time to listen to and talk with a patient? Value, absolutely! But illegible orders, or unclear explanations of prescribed medications? Once again, and I think TB12 would agree – not value. Unfortunately, these cost money and most health systems still charge for them, and they constitute a large portion of our national healthcare bill.
In his book, On the Mend, Dr. John Toussaint, former CEO of ThedaCare in Wisconsin, now CEO of the ThedaCare Center for Healthcare Value, describes an even more challenging view of value in the care for an emergency patient with a STEMI heart attack. ThedaCare defines value as the moment when a balloon is inserted into the patient's blocked artery, removing the blockage and allowing blood to flow again. Touchdown! The ambulance ride, triage, EKG, ER doctor, cardiologist, movements from one room to another, and the travel time of the Cath Lab staff to get to the bedside? ThedaCare views these like Brady views holding the ball – non-value to be minimized.
Brady and Patriots coaches also seem to understand the importance of the “gemba” and “going to see.” Gemba – where the work happens, where value is created, and where waste and problems are found and best addressed. Strategies and plans based only on reports and data, without going to see at the gemba, fail in many, important ways. That's not the Patriot way.
“I've never been too much of a tablet guy – I kind of know what I see,” Brady said, referring to the team's tablet PCs (see Mark's recent post about them).
“I see out there and as soon as I come off the field, Josh [McDaniels] will say, ‘What was it?' and I'll say, ‘Oh, they did this and this guy dropped.' …It's great for the coaches because they have a different angle. It's hard to see when you're seeing from the sideline. When you're out there playing, a lot of times I can come over and tell Josh, ‘This is what happened and here's why we did that.'”
On the field, Brady is in the gemba and has the best view of problems and opportunities. His input from the gemba is crucial to the coaches and assistants on the sideline who develop game strategies and call most or all of the plays. They respect each other's expertise. Coaches might use tablets to get another perspective, but without seeing through Tom's eyes, their strategy development and play calling would clearly be very average at best. Lean practitioners might recognize this real-time, back and forth trading of insights, ideas, and plans between leaders, managers, and their front-line staffs as “catchball”, a relatively unfamiliar concept in traditional, top-down business management and strategy deployment.
Do your healthcare leaders call plays from the sideline, from their laptops and conference rooms, away from the place where value is created and problems are solved? Are front-line staff able to convey what they're seeing, and what they need to succeed, in a catchball-style conversation? If not, leaders might try spending more time in the gemba and ask the players there what's happening, why, and what they think should be done to improve the next case, the scheduling of the next patient, the next post-acute follow-up to prevent avoidable re-admissions. Respect that input and the people who provide it.
Standardized Work … and More
Brady's just getting started with his lean thoughts. He touches next on standardized processes; the value of practice, like pilot testing a new process change; and celebrating.
“The week of practice is very helpful. This week has to be a big week for us because every week it changes. You win the game, you go home and celebrate, and then at some point you shift focus to the next week and you've just got to put the same process in in order to try to get the same results.”
The same process, to get the same results. Sound familiar? Does patient care change every day? Absolutely. How about standard processes for care that staff study, practice, and follow? This is different from what's taught in medical, nursing or other clinical academic settings. Standard, reliable, repeatable processes are designed and developed in the gemba by the staff who do the work every day, and should be guided by local data and knowledge of best practices.
Tom Brady might not call this lean thinking, and there's nothing wrong with that — it's not about the terminology. But it's instructive to hear the members of pro football's leading franchise in recent history, using these same principles to achieve consistently outstanding results, even through injuries and regular staff turnover. If you have any football fans among your staff, especially those who are new or a little resistant to lean, I hope you'll share this with them. Good luck!