I tried something last year with a reflection on 2013.  I am giving it a go again this year.

Here’s what I learned about Hansei.  It is my understanding that “Han” means to change, turn over, or turn upside down.  “See” means to look back, review, and examine oneself.  I understand that there are 3 elements:
1. The individual must recognize that there is a problem – a gap between expectations and achievement – and be open to negative feedback.

2. The individual must voluntarily take personal responsibility and feel deep regret.

3. The individual must commit to a specific course of action to improve.

The theme for this year’s reflection is “tending a network”.  This is a term I learned in 2014 from Brint Milward, a professor at the University of Arizona who studies networks.  His research is around networks that are organized around both good things (like our Healthcare Value Network and Clinical Business Intelligence Network), and bad things (like terrorist networks).  I like the term “tending” a network because it reminds me of “tending a garden”.  As in gardening, there is always work to be done, but at the same time there must be a willingness of “letting go”.  It is the balancing of opposites.  You don’t manage a network like you operate and improve a machine.  Anytime there are people involve, you need to allow for free will and creativity.  You need to count on it.

As I reflect on 2014, with the idea of “hansei” and “tending a network” in mind, here’s my “top 10″ list.

10. Similar to last year, I’m preparing a paper to present at the 21st Annual International Deming Research Seminar, March 23-24 in Washington DC.  I blogged about this year’s topic previously.  I’m learning a lot about current state in some healthcare organizations.  Writing is a good way to learn, and to try to get clear on thoughts and questions.  But it takes time, and when I’m writing, it means I can’t do something else.  Something’s gotta give.  It starts with a paper, and may become a book.  An idea I am working on with friend and colleague, Mark Graban.

9. My “number 8″ item last year was the idea of Regional Group Meetings for Healthcare Value Network Members.  Last year it was just an idea.  People benefit greatly from face-to-face interaction, but not everyone has time or dollars to travel to our traditional 1.5 day gemba visits.   Those who are interested can come and go in the same day.  We have tested it a few times, and it seems to be getting some traction.  We had one meeting in Scottsdale, AZ, another in Cleveland, OH, one in Allentown, PA and most recently, one in Boston, MA.  I blogged about this idea here.  This seems to be a useful addition to our offerings.  The reflection on this point is that all of our Network members are busy people.  Everyone has a “day job”.  Planning and convening these meetings won’t work if we do this FOR people.  We need to do this WITH people.

8. My “number 7″ item last year was the progress we have been making on education about and application of our HVN Assessment Model.  This continues, and is gaining more traction and utility.  When we got into this work in 2009, we saw this as a model for “assessment”.  Now I think we are seeing it as a model for transformation.  Not THE model, but A model.  All models are wrong (in some world), but some models are useful.  I think we are finding this model to be very useful.  Here’s one of my blogs on this topic.  Here’s another.  The reflection here is continued learning about the model and making it accessible and useful for others.  We need to keep the “pracademic” view (term I learned from friend and colleague, Jake Raymer).

7. We helped our member organizations host 12 gemba visits in 2014, and we provided access to 7 non-healthcare visits.  We tested the idea of a virtual gemba visit where we provided access through videos to see the great work going on at one of our member organizations in Ohio.  Work is in process to provide similar virtual visits from videos taken in 2014.  We learned that this takes a lot of work once the videos have been shot, and we need to build the expertise (and allocate the time) to editing if we continue in the future.

6. We offered 35 webinars to HVN members in 2014.  The topics have been wide-ranging, and we have learned that it is a good way to share the great work our our Network members.  We’ve learned a lot about what works, and doesn’t with the webinar platform, and we’ll be testing some changes in 2015.

5. We have 2,349 people who are signed up on the private HVN Collaboration website.  Last year that number was 1,964.  We made some adjustments to this tool, and more will be required in 2015.  We’ve gotten more comfortable with the Ning platform.  I have found the book “Ning For Dummies” to be quite useful.

4. Last year I described how I was trying to feature some of the great work that is going on every day “in the trenches” on this blog.  There were many mentions in 2014: New England area members, an example of a leader, the ACT Fair in Scottsdale, AZ, Oregon Tour, Survival Is Not Compulsory, Learning About Principle-Based Lean Transformation, Southern Illinois, Vancouver, BC, Dancing With the (Lean) Stars, Board Of Directors Huddle,Kitchener, ONT, Best Conference Ever (Till Next Year), T-Minus 20 Days, Small Improvement/Huge Impact, Constancy Of Purpose, Tucson, AZ, It’s About the Patient … Period, Saskatchewan, What Needs To Transform?, One Example of the HVN Assessment Process.

3. Our Network Team works with other value streams at the ThedaCare Center For Healthcare Value, and this work helped out Network member organizations, but has also helped to bring about transformation in healthcare.  Some key achievements and learnings from these areas include: Connecting lean thinking and Clinical Business Intelligence, and It’s the System (the book by Kim Barnas).  We’ve also seen the introduction of a tool into our CEO Site Visits that takes what we’ve learned from our HVN Assessment work and helps people see beyond (beneath?) the surface tools, and helps them understand systems and principles.

2. My “number 2″ item last year was a desire to continue to help Michael Grogan and the people at CCBRT with their effort to get some “boots on the ground” help for their work in Tanzania.  Our CEO, John Toussaint, MD was able to travel to Tanzania and see first-hand the great work that they have done.

1. Some days it feels like great progress is being made, other days it feels like two steps back.  People are working hard, and many people deserve a hug for their efforts and their courage.

What is your hansei for 2014?

People want better results.  I hear it every day.  Costs are over-running revenues.  There are too many customer complaints.  There are too many patient injuries and even deaths.  Yes, people want better results.  And I’ve heard people say that is management’s job … to get results.

But by what method?  There are lots of ways that you can get results.  I recall Dr. W. Edwards Deming saying on more than one occasion, “Anybody can make anything happen if they don’t count the costs!”  Managers can get better results (short term) by threats and punishment.  We can (and do) get better results every day through heroic efforts, fire-fighting and best efforts.

People hear about “lean” and they understand that you can get better results through this methodology.  So, they start their journey.

They read some books, engage with some consultants, organize some teams and learn some tools.

This isn’t wrong.  It’s a common way that people learn the principles behind lean-thinking.  Getting a team together and improving the work using an event and introducing tools does work.  And the results often follow.

There’s so much waste, inefficiency and variation in healthcare (and other industries) that it would be hard not to get some improvement.  The trend looks positive and people are encouraged by their work.

But the improvement does not last.  Not by this method alone.  The improvement starts to slip.

The typical response is to re-frame or re-name the effort (with some more tools), and sometimes we see some renewed improvement.  But it too does not last.

The actual rate of improvement remains flat (or goes down in you factor in advances made by your competitors).

Lately, I’ve heard a lot of talk about “creating a lean system”, and I also see people trying to copy what others are doing (they’ve gone beyond copying the tools, but are now trying to copy the system).  It may be “directionally correct”, but will it result in sustained improvement?  Much of this appears to be resulting in a churn of activity, but not sustained improvement.  Time will tell, but I think there is missing puzzle piece.

In 1980, Dr. Deming was interviewed for a program that aired on NBC “If Japan Can, Why Can’t We?”  In that interview he said, “people go to other companies in other countries and they want to copy what they are doing.  But they don’t know what to copy!”  He was talking about the thinking, which can’t be copied.  Completely different mental maps are required, new wiring in our brain.

Many organizations give up on this lean stuff at this point.  “This stuff doesn’t work in healthcare”, they say.  And it’s off to the next shiny object.

What’s missing?  The model for improvement is incomplete.  There’s an entire “undiscovered country” that is not often understood.  It’s not even under suspicion.

There are principles that need to be understood, and not just any principles.  What do we mean by principles?  Imagine you wanted to build a house.  In order to do this, you would need to learn the principles of house-building.  This might include some principles of geology (the foundation for a house) and the principles of different building materials, and the principles of architecture.  If you went about trying to build a house without understanding these principles, you would have problems. There are consequences of not understanding principles.

The same is true for business (and healthcare is a business).  There are certain principles for achieving excellence in all parts of your business.  There are principles of working with and enabling people, principles of improving the work, and principles of working on the right things (the things that provide value to your customer).  What are some of these principles?

Here’s a list:
Enabling principles –
Lead with humility.
Respect for every individual.
Learn continuously.

Improvement principles –
Seek perfection.
Provide quality at the source.
Flow and pull value.
Embrace scientific thinking.
Focus on process.
Understand and manage variation.

Alignment principles –
Think systemically.
Work toward constancy of purpose.
Provide value to the customer.

Are there more principles? Yes, probably.  But this is a good start.

The thing about these principles is that these are not the principles that most managers have learned and for which they have been rewarded and recognized.

The prevailing style of management does not reward “leading with humility”, but tends to recognize and reward managers who have all the answers, or solve the problems, heroic efforts and hard work.  We value superstars.

The prevailing style of management does not reward or recognize “respect for every individual”.  If it did, we would not see the focus on the individual when things go wrong (blame and shame).

The prevailing style of management does not reward continuous learning, not really.  The focus is on results.  Curiosity, asking questions, learning about and embracing the current state is not what management is paid to do.  The learning seems to have stopped once the degrees were conferred.

The prevailing style of management does not reward “seek perfection”, perhaps it rewards “demand perfection” or “achieve perfection”, but that is not the same thing.  Seeking perfection is never-ending, ongoing effort to provide value to the customer.  When management says “things are good enough” or shows a scorecard that is all “green”, there is something amiss.

The prevailing style of management does not reward or recognize providing quality at the source.  The prevailing style depends on and builds in inspection – checking, double-checking and triple-checking.  Passing defects along is a way of life.  We don’t even see the defects.

The prevailing style of management does not understand much less reward and recognize “flow and pull value”.  Information and problems are batched.  We save items for monthly or quartely committee meetings.  Waiting is built in to our processes.  We even have rooms just for waiting.

The prevailing style of management does not embrace scientific thinking.  Instead of Plan, Do, Study, Act (or Adjust), we tend to see Plan-Do, Plan-Do, or Do, Do, Do.  Scientific thinking means developing a hypothesis about what is going on, and a hypothesis about what might lead to improvement, and testing that hypothesis and studying the results, then adjusting accordingly.  Not once, but continuously – forever.  Most managers don’t see their job as running experiments.  The focus is on results.

The prevailing style of management does not focus on process.  The tendency is to focus on the individual when things go wrong (or even when they go right).

The prevailing style of management does not include an understanding of variation or how to react to variation.  The tendency is to react to every outcome as something that needs to be investigated and corrected.  Understanding the difference between random (common cause) variation and assignable (special cause) variation seems to have eluded management, and the schools that management attended.  For some reason “understanding variation” has been equated with statistics, or six sigma, or other mysterious areas of specialty.  The most important application of this principle applies when we don’t have data – it applies to the management of people.

The prevailing style of management does not reward and recognize an understanding of “systemic thinking”.  The current tendency is to chop the organization up into parts and try to manage the parts as if the organization were additive.  The prevailing style thinks in terms of linear, cause & effect.  If we see something, we think it is entirely logical and rational to find the one cause.

The prevailing style rewards and recognizes short-term thinking and results, not constancy of purpose, long-term.

The prevailing style of management does not reward and recognize providing value to the customer.  The tendency seems to be to focus on what the boss wants.

I could go on and on.  We have a lot to learn (and unlearn) around principles.  Myself included.  Creating new mental maps is hard work and is not easy.  It takes deliberate effort, new experiences, a willingness to experiment, and patience (with each other and ourselves).

When we do understand these principles, it affects the kinds of systems we design (or how we adjust our existing systems).  Now when we turn our attention to systems we will increase the likelihood of sustained improvement.

What is a system?  Dr. Deming defined a system as “a network of interdependent components that work together towards  common aim”.

Systems are not new things.  They are all around us.  Our body works as a system – actually a group of systems (respiratory, cardiac, muscular-skelatal, etc.).  We deal with systems every day.  The transportation system is an example.  It is comprised of interdependent components (traffic signals, rules, police, education, training, highways, signs, gps) that work together toward a common aim (help people and things to get safety from one point to another).

Systems are comprised of tools (among other things).

We have a lot to learn about systems.  One thing we need to understand is the affect that systems have on behavior.  Systems drive behavior.  That’s why we all drive on the right-hand side of the road (in this country).  That’s why we stop at a red light.

People say they want to create a culture of continuous improvement, that they want to change the culture in their organization. A company’s culture includes the collective behaviors in the organization.  The behaviors of top management, middle management and the front line.  If you want different behaviors, there are really 2 levers to pull: 1) what gets measured (especially if it is made transparent).  As soon as you start measuring something and making the results visible to everyone, the behaviors change.  But that is not sufficient.  2) Because systems drive behaviors, we need to think about what kinds of systems (and behaviors) we want and we need to learn how to design and adjust our systems.

It’s the system.  But it is also the principles behind the system.

It’s also important to be clear on the roles and responsibilities.  Top management needs to own the principles.  Their understanding of these principles, and the behaviors exhibited by this understanding, sets the climate for the organization and is the primary way they contribute to the results of the organization.  Middle management are the primary owners of the systems.  They design, redesign, measure, monitor and maintain the systems.  This is their primary contribution to the organization’s results.  The front-line workers are primarily involved with the daily use of tools and methods (parts of the systems).  They need to own, design and redesign these tools.  This is their primary contribution to the organization’s results.

When I ask questions about who owns what in this model, I often get these answers: Who owns the tools?  The typical answer is either “management” or, more likely, “the lean team”.  Who owns the systems?  The typical answer is, “what systems?” or more likely, “what is a system?”  Who owns the principles?  The typical answer is silence.  Some principles may have been discussed or embedded into some courses, events or workshops, but they are not usually made explicit.  They ware not typically reflected upon and the correct ownership (top management) is not well understood.

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NOTE: I did not come up with these ideas.  I learned this from several sources including the Shingo Institute and the Institute For Enterprise Excellence., and the Lean Enterprise Institute.  I also learned a lot (and continue to learn a lot) from the work of W. Edwards Deming and the Deming Institute.