Visual management - Leadership Support for the Front Line


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Visual Management is a lean communication tool to help keep focus on priority initiatives in the workplace as well as keeping your thumb on the pulse of daily operations. I will take you through the evolution of one areas visibility management system and how this has now spread through all divisions of our Pathology and Laboratory Medicine Department to become standard work. You will take away ideas and inspiration to incorporate this communication system in your workplace. Success comes from ensuring the loop of communication goes full circle from leadership to front line and back to leadership for full understanding.

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  • Good Morning Everyone
    I have been asked many times by people who visit our leadership daily huddle in the lab at SPH –
    How do you do it?
    How did you get to this state in your operations?
    They then recommend others to visit. It is something which has to be seen.
    Some visit and say “Ya that works for them but it will not work for us”
    I am here today to try and explain how we got to the state we are at today so it may help you and others.
    I will try and explain how I got the leadership visibility management system set up in the lab at SPH and how it now connects to our Regional Laboratory Operational Committee Visual Board which then connects to SHR’s Organizational Visibility Board. A true cascade of communication.
    I have been involved in a journey of Lean Learning since 2006. I have not been trained by John Black and Associates but have the theories of Lean ingrained in our Daily Operations at SPH Laboratory
    I feel the culture change -
    Before I show you the Visibility Boards in the Lab I would like to review my thinking patterns of how they developed so you can better see how it created over time.
    A fellow Lab Technologist and I were at our Provincial Conference just prior to the Vancouver Olympics in 2010 and just reported on our Lean Pilot Project.
    On the way back to Saskatoon we were talking about if this was going to be “The flavor of the month and if it would now be spread within SHR”
    As you may have read in many articles about Lean it is a transformation over time – not the flick of a switch
    We came to the decision that if it was take hold within our laboratory department we would see effects by the next Winter Olympic Games
    I kept the vision of Sochi in my view for 4 years as a timeline of cultural change.
    We have continually improved our business of delivering results in accordance with the focus on the Principles of Lean and using many of the tools within the Lean toolkit to help us succeed. The journey never stops and the base knowledge of success is to know the system and ensure communication. One can never communicate enough it seems.
    Before I go over the visual management system currently in place with SHR Laboratory Services I would like to review some concepts which are the foundation of this System
  • I am unsure if everyone here is education in Lean – This is the visual of Lean Principles - Continual Improvement for Perfection
  • Words to input into each Principle I use in our operation for staff education and understanding.

    A visual management system is connected and cascades communication in both directions continually over time– ensures communication of goals as a focus at all levels of the system – what is the connection for focused effort to accomplish the goal at each level – clearly identified and discussed regularly.

    I would like you to view this video and see if you see any similarities to your workplace.

  • Organizational Goal Communication is a challenge of most leadership teams.
    How can you start to do something you have never done before?
    Remember these key points going forward no matter what stage you are at.

    Not every front line operation is identical – they have differences which need to be captured – they change dynamics daily
  • I am going to touch on three vital components required for front line visual boards
    I will not go into detail about each one. There are great coaches within our system to get this education.
    I persued this education through the HQC – Quality Improvement Consultant Education – We now how Leaders/Coaches within the Kiazen Promotion Office
    Leaders need to ensure they seek this education/mentorship/coaching in each of these areas to support the front line getting to the bottom line
    Leadership development is a key to success for communicating strategic goals and tracking results
    You need to have a leader with the vision to get there – stay the course.
    We learned this in our Lean pilot – now we have operationalized monthly education sessions for regional supervisors/managers/clinical dyad leaders. Process Improvement learning is one component of this leadership development plan.
    The Value Steam is composed of these three componets which then comprised a picture of understanding the SYSTEM
  • Map out your processes for full understanding.
    When it on paper more conversations take place. People start to understand other components connected to them but they may not be directly involved in.
    They may even have engrained assumptions and judgments in place for a connected process which need to be broken down.
    “I don’t do it that way” Why do you think it is done differently? May be an opportunity for improvement.
  • We have applied different tool to develop improvement for the staff who work our processes to ensure quality is part of our everyday work
  • Measurement if a passion of mine and not one of all people around you.
    Measurement takes some of the emotion out of conversations for objectivity.
    It can also add some emotion, as I have found out. You measured the wrong day, you missed measuring a vital step. The front line will critique the measurement to confirm you have done it correctly. This is vital to ownership of the process measurement. If they don’t trust the measurement they will never own it. Have them pull the data and plot the data. Make it tangible to them.
    All is good and you need to listen to ensure you capture a good measurement and all staff involved in the process measurement are comfortable with how it is captured. Not hidden agendas.
  • OK
    Now we have some basic components to talk
    Remember – Process/People/Measurement – all components of a value stream map – System thinking
    This is our very high level process view of how specimens move through the lab at SPH.
  • Each area has staff who work within it to ensure the product is accepted by the next – internal quality checks are built in – staff have the authority to stop the line, make a correction to ensure quality results are released.
  • We continually review the level load the work -
    Across all shifts – one shift should not be a burden over another
    Continual pull of work for continual flow
    As concerns come forward we have the ability to pull data for analysis
  • We established a meaningful measurement from our Lab Information System
    Not the BEST type of measurement – good or bad for judgment (bucket data – attribute data) – but often it is to hard to achieve the best so go with what you have.
    You must learn to understand measurement – connected to understanding the variation of the data from the system – best is variable data over time with each value having a time.
  • The laboratory has a lot of automated equipment now and if a piece of equipment fails our service is drastically affected.
    This is a focus in many of our labs and has become a component of many boards
    Training is required for lab staff on an annual basis as well as one time only – Each month or two we have an identified regional focus of a training requirement Jan = EPP Feb/Mar – Annual reading of Safety documentation. – tracked on boards for completion and if additional supports are required.
    5S + Safety – Many areas have undergone 5S initiatives. Sustainability is only achieved if reviewed regularly – suggest every 6 months – include safety into the walk through focus and it will connect with OH&S regulatory requirements. Document and track recommendations of actions moving forward
    Projects for Improvement – how many are happening – who is involved – regular report outs – tracking to completion into operations.
  • Like Steven Covey stated
    “To achieve something you have never achieved before, you must start doing things you have never done before”
    Try new things, different ways, test changes
  • We cannot improve the system if we don’t take time to fully understand the system
    Deming outlines 4 areas of systems which are all interconnected and require focus in all equally to be successful
    Goldratt outlines how to understand constraint within the systems moving parts to achieve success
    Deming – System of Profound Knowledge
    Goldratt – Theory of Constaints

    OK enough to the teaching component. Now let me show you have we have put all this theory into practice for standard work

  • Now let me try and show you how I put the principals of the theory into practice for standard work and the development of a Leadership visibility board within the lab at SPH over time.
  • I moved into a Managerial position Sept 2011 – 1st priority was to visually bring together 3 areas of work as a team
    Each area worked very independently of one another even though the delivery of one area was the input of the next.
    There were a lot of assumptions and judgments in the workplace between the areas
    I had directly worked in two of the three areas as a front line worker for 10years previously but had not worked in the area directly for up to 2 years.
    I gotta tell you from the front line to the director they were really wondering about my new system of management
    They went with me on the journey and we kept trying new things, new angles for understanding
    I was challenged for sure but kept the focus of a visual management system moving forward with the feedback and conversations.
    The supervisors would filled in the information as required at the start of each day and we talked about it every morning during the leadership huddle
  • We trialed a new looks and a location – We moved the huddle to the front door – not behind a door
    We started to incorporated measurement of process (TAT) and system (OT and Sick Time) –
    We started reviewing the variation connection of outliers for improvement
    What happened yesterday that we can learn from for today?
    These words were posted at the top of the board to ensure the question was asked each day or as required.
  • Movement to a permanent white board at the front door location - works
    Permanent markers were used to identify processes and staff shift associated with each process (bench assignment)
    Check marks are filled in by area supervisors each morning to visually indicate staffing levels
    At this level I don’t have to know staff names – As a manager I need to know we have supports in place for the front line to accomplish our daily targets of service
    Do we need to network with other managers for additional support from other points in our region to be successful?
  • Sectioned off processes – Identification of staffing to process

    Note process improvement board – Today we have fewer initiatives prioritized for FOCUS, huddle reports on Fridays are shorter over time.

    Note the process Improvement section – we had LOTS going on –we took everything begin worked on in each area outside of regular operations and wrote it down
    We talked about each one and started to prioritized them – made headings of Impact (Area/site/regional?), Name – Action being worked on – Who was the lead – Next Report date.
    We collaboratively determined how to focus and finish to get through the list
    Projects seemed to be assigned to individuals but the individual is not set up for success as a team leader unless it is an area focus for completion.
    Knowing that it was listed was important to ensure it was not lost and would be completed as each one was completed – it had no identification to the leader it was prioritized within the system.

  • Opposite wall has indicators or reports connected to our Department as a whole within Saskatoon Health Region for visibility and tracking.
    Strategic Planning
  • Often staff on the front line do not ever see other areas within the system so this helps them have the connection to this other work being done.
    Everyone in the system is connected.
    How does leadership visibility board now connect to the front line and the Laboratory Department System.
    Huddle cascading which is connected and linked for a system communication plan.

  • The Cascading huddles keep the thumb on the pulse for the goals and priorities within the Laboratory Medicine operations as well as any connections to the organization of the health region as a whole.
  • Communication tool of Supervisor with Manager and Clinical Staff
    Supervisors use the Work Record A codes for absences on the leadership board ID = sicktime HC = vacation FL = Family Illness etc. OT = overtime and amount anticipated, etc.
    We established staff contingency plans to ensure deliverables of performance targets. Some days we do not have enough resources and have to make tough decisions. Staff need to know it is OK to NOT do something today and they are supported. The work will be continually reviewed. Clinical staff are involved in this decision making process.

    Each supervisor identify any constraints they anticipate for the day and we discuss as a team if we required a support plans.
    The Daily indicators are erasable/dynamic – cleared at the start of each week
  • We have an ongoing conference call connection set up in our outlook calendars to link us all together each day – all sites – all area
    Each manager does a 5min report on standardized items for the huddle
  • Any anticipated OT is identified
    Shifts above base = staff doing additional training or orientation – this is identified on the visibility board.
  • Staff names are important on front line visibility boards
    The names are put on the board the evening before by staff and if any changes are required due to short term absence the area supervisor or designate does the changes the next morning before 0800hrs and bring the information to the 0800 leadership huddle for understanding and supports if required.
    If I have anything which comes to me as a manager as the day progresses I identify how to communicate it out.
    Does it pertain only to one area or all?
    If only one area I will take it to their board and discuss with the area supervisor to mention at daily area huddle – If they need my support at the huddle it is identified and I attend.
    If it pertains to ALL staff I determine if it can wait till Monday’s General huddle or needs to be communicated to all supervisors at Daily huddle who then take it to their daily huddle.
    Process measurement is a standard component of visibility on the front line – they own it and need to discuss outliers in a timely manner to explore how to improve through process improvement or additional supports
  • The weekly huddle reports for the Lab Operations Committee align with the Organizations SHR huddle reports given on the Tuesday prior.
    Our Director, Judy Archer, brings information from the SHR Tuesday huddle to our LOC meeting for shared and discussion in her communication report
  • We find our connection to the Organizational Goals and Priorities.
    Hand Hygiene
    ED Optimization – we need to ensure our Lab service is not a restraint on patient flow in this area – tracking of outliers within our TAT data and communication of our service targets
  • We are moving the system of cascading huddles forward to help reach our goals
    I recently read an article about two major companies – Yahoo and Best Buy – they are both moving away from the popular concept of telecommuting (working from home)
    They found they were relying on connection through email communications – conversations were often being misunderstood and hard to understand
    Yahoo has stated “there is a need for communication and “physically being together” as necessary for progress”
  • Try it, Test it, Learn from it
    You can walk, you don’t have to run
    You have supports in place, reach out and use them

    Different team will be a different stages of learning and development. That is OK. Talk to those in front of you and behind you for learning. We are on the same team – same Goals
  • We are on the same team and through a visual management system we will stay focused on our Goals.

    PyeongChang- Korea
    How will the culture of Visual Management spread before 2018.
    Lets take up the challenge – we can do it as a team.
    Lets do it for Patient Care
  • Visual management - Leadership Support for the Front Line

    1. 1. Daily Visual Management System Leadership Support for the Front Line Lenore Howey – Laboratory Manager #QS14 BETTER TEAMS
    2. 2. SHR Laboratory Lean Journey Continues … Implementing Daily Visual Management into Standard Work 2006 ... 2010 … 2014…
    3. 3. Define Value Value Stream Create Flow Establish Pull Pursue Perfection Lean Principles
    4. 4. Define Value Performance Value Stream process understanding Create Flow eliminate bottlenecks Establish Pull continual beat Takt time Pursue Perfection continual improvement Lean Principles
    5. 5. Visual Management System Lean Communicational Tool Visual Priorities – Goals Visual Indicators of Performance All are tied to a System at different levels
    6. 6. STEVEN R COVEY the community – empowering your greatness ces/companion_films.php?f=12&s=l
    7. 7. Visual Boards • The end result must work for the area (level) • Different is OK • It is not about the board, it is about results • Objective of this presentation is to give you ideas to try (PDSA) for your daily visual management system. No involvement = No commitment Front line produces the Bottom Line
    8. 8. Value Stream Process + People + Measurements Value = Customer (Patient) Goal = Performance Target Leadership Development Understand your Value Stream of service Base = system understanding
    9. 9. Process Integrated steps/procedures in a system • Each step/procedure is separate and unique • Each step/procedure is connected The whole is only as good as the sum of the parts
    10. 10. c
    11. 11. People • Education – skills, ability and knowledge • Right person doing the right job Tools • Standard Operating Procedures • Competence reviews • Performance Capacity and Variation • Schedule assignments to workload
    12. 12. Measurement/Data/Performance Data required for objectivity of understanding Some is not a number Soon is not a time
    13. 13. SPH HV Lab Physician Order Specimen Management HematologyChemistry Results Patient Acute Care Wards Patient Collection Centres Physician • High Volume Laboratory • Delivery of Test Results • 5 areas of work • Each area has internal processes • Each area is connected • Customer only feels the system results
    14. 14. PEOPLE Who does What? When? How?= Standard Work
    15. 15. People = Scheduled to Workload - Level the Load Data Entry Report Dist. HematologyChemistry Patient Collections Acute Care Wards 10 Storm (7-9am) 4 Days 3 Evenings 1 Nights 3 (8-12) 2 (12-230) 5 Days 3 Evenings 1 Nights 7 Days 3 Evenings 1 Nights Patient Collections SPH Test Centre 5 Days 3 Evenings Specimen Management 2 x 12hr 1 x 8hr (T,W,Th)
    16. 16. Measurement – TAT 70% 80% 90% 100% TATPercent SPH Emergency Phlebotomy- Collected to Rec'd in Lab Target: Stats<15mins Urgents<30mins Focused initiative to ensure timely return of Emergency samples Thumb on the Pulse – Daily Measure Timely review of outliers
    17. 17. • Equipment • Training • 5S + Safety • Celebrations • Process Improvement Monitoring • Rock in your Shoe – front line identified concerns/constraints Additional Components of Visual Management System
    18. 18. Step out of Comfort - PDSA • How can we learn if we don’t try • Failures teach us • Not always about the success • Predict and test the theory • Reflection and refocus • Cycles repeat
    19. 19. Base = System Thinking Learning Know Quality is a Systematic Process Theory of Knowledge Psychology of Change Understand Variation Application of a System
    20. 20. System Thinking KnowLet’s put it all together for Visual Management
    21. 21. 1st PDSA of Daily Management – Fall 2012
    22. 22. 3rd PDSA – Jan 2013
    23. 23. 5th PDSA – June 2013
    24. 24. Daily Management April 2014 Process + People
    25. 25. System Monitoring
    26. 26. Daily Management System Connection of all parts = System Standard work to ensure Front Line is supported “The Front Line produces the Bottom Line”
    27. 27. Daily Huddle Communication Cascade Time Mon Tues Wed Thurs Fri 0800 Daily Leadership – daily review system - people/process/measurement 0830 Daily Managers/Director – daily conference call SPH Site SHR *SLT Lab *LOC 1000 General staff Huddle – SPH Laboratory 1300 Hematology 1500 Chemistry Front Line daily huddles – area specific 1500 Spec. Mgmt
    28. 28. 0800hrs = Front Line Leadership Huddle 30 min max
    29. 29. 0830hrs = Manager/Director Conference Call Daily LMM Report Out Lori Goldie Lenore Diane Betty Lorrie RRS Histology Cytology Clerical Autopsy LIS SP Man DE Chemistry Hematology Chemistry Phlebotomy Bacteriology Virology Molecular TB Process Workers, MOA Immuno TML HLA Cytogenetics RUH Hem HMG Saturday OT (hrs) Sick Time/Family Leave (# of staff) Shifts above Base Shifts NOT replaced Operational Issues Staff Injuries-type Sunday OT (hrs) Sick Time/Family Leave (# of staff) Shifts above Base Shifts NOT replaced Operational Issues Staff Injuries-type Monday OT (hrs) Sick Time/Family Leave (# of staff) Shifts above Base Shifts NOT replaced Operational Issues Staff Injuries-type Tuesday OT (hrs) Sick Time/Family Leave (# of staff) Shifts above Base Shifts NOT replaced Operational Issues Staff Injuries-type Wednesday OT (hrs) Sick Time/Family Leave (# of staff) Shifts above Base Shifts NOT replaced Operational Issues Staff Injuries-type Thursday OT (hrs) Sick Time/Family Leave (# of staff) Shifts above Base Shifts NOT replaced Operational Issues Staff Injuries-type Friday OT (hrs) Sick Time/Family Leave (# of staff) Shifts above Base Shifts NOT replaced Operational Issues Staff Injuries-type 30min max total
    30. 30. Standard Template for Report Lenore SP Man DE Chemistry Hematology OT (hrs) Sick Time/Family Leave (# of staff) Shifts above Base Shifts NOT replaced Operational Issues Staff Injuries-type
    31. 31. All Laboratory staff SHR System connection communication SHR –Leaders Connected Sharing SPH – 0830 Monday site huddle Regional Laboratory – previous week LOC SPH Laboratory – staffing, lab specifics Celebrations – from staff, site, region Notes sent via internal mail message 1000hrs = General Huddle - Monday 30min max
    32. 32. Chemistry 1500hrs – Front Line Huddle 15min Target 30min Max
    33. 33. Hematology 1300hrs – Front Line Huddle 15min Target 30min Max
    34. 34. Spec. Management 15min Target 30min Max 1500hrs – Front Line Huddle
    35. 35. Week 1 = Quality and Safety Week 2 = Deliverables Week 3 = Cost Week 4 = Strategic Projects Clinical Department Head Director Managers Clinical Dyad Leaders 0830hrs *LOC = Thursday Lab Operations Committee 1 hour Max – 3 min takt report 5 Divisions 3 Urban + Rural
    36. 36. SHR Leadership Visibility Board Senior Leadership (SLT) Huddle Saskatoon City Hospital Organizational review of Goals/Progress Week 1 – Quality and Safety Week 2 - Deliverable Week 3 - Cost Week 4 – Strategic Plans/Reports Tuesday
    37. 37. Huddles = Regroup/Refocus Visual Boards Eye on the GOAL Communication Each level connected Cascades
    38. 38. Feedback Dr. Andrew Lyon (Clinical Biochemist - SPH Lab) - it is in a high traffic area and everyone coming in and out of the department can check it at a glance. - ‘easy?'........some days when problems are repetitive, it is a bit harder - It makes me feel more 'connected' to the lab staff - Don't forget to put up celebrations & fun things
    39. 39. Feedback RUH Phleb – Staff feel the board is theirs – they write down items they feel should be “huddled” Manager – Thankful our huddle system was in place when Level 4 organism was suspected. Daily communication system was already standardized Director – • feels better connected to what is going on even when I’m not at the huddles • “Rich” conversations are vital to understand • Not about the look of the board, it’s the conversations, interaction • See progress “at a glance” when on Gemba walks
    40. 40. Pursuing Perfection Predictable Reliable Defect free No Harm
    41. 41. We are all on the same road Imagine what we can do Make it VISUAL - Communicate
    42. 42. Through focus we will reach our Goals Together Visual Management System
    43. 43. Questions? Contact Me: Lenore Howey Laboratory Manager, SHR #QS14