On July 16th 2015, Robert McDonald, Secretary of the VA released this memorandum to the VA:
"To better serve our customers, the VA must synchronize and better leverage our performance improvement efforts. Improved service to our nation's veterans requires a cultural of continuous improvement and networking between and across administrations and staff offices. Developing this culture of continuous improvement department-wide will leverage the numerous pockets of excellence within the department and further enhance our employees' sense of purpose. This memorandum outlines the strategy to fully implement the "Lean" strategy and processes to make the department more responsive to our customer's needs." The memorandum goes on to discuss some of the details.
This move on the part of VA leadership may be the watershed moment that will turn around VA operations. If the VA is to be successful at a lean transformation what will it take?
I have studied many organizations around the world committed to this transformation journey. In my new book Management on the Mend I have documented my findings. I highlight eleven organizations in the book but could have highlighted dozens more. Out of this study has come a framework for successful transformation. It starts with the leaders.
True North: Leaders have some important work to do in order to ready the organization for transformation. The number of strategies and metrics must be winnowed, especially at the VA where there are hundreds of metrics. The metrics must be reduced to the critical few. This is called True North. At the VA, my suggestion would be make sure wait time is included in the handful of True North metrics.
Principles: The lean transformation depends on a set of principles. These principles lead to the development of systems, which over time, change behavior. For example, problem solving using scientific method. This principle leads to a system of identifying and solving problems each day using Plan-Do-Study-Adjust (PDSA) thinking. PDSA replaces shame and blame if a problem arises.
Improvement team: The VA needs a central improvement team. My suggestion is that improvement teams should be deployed throughout the hospitals and clinics, and coordinated by a central body so there are standards established across the system. This team will support the development of model cells.
Model cell: In every VA organization there should be focus on creating "what good looks like" uniquely for that place. The work of radical redesign should be applied to one clinic or one ER, then the systems and thinking spread to other units or clinics. This is an inch wide, mile deep approach. A Model Cell is what staff need; to be able to visit and see the difference for themselves.
Management System: Underpinning any successful lean transformation is a change out of the existing management system. The usual autocratic approach to healthcare management destroys the willingness of front line staff to identify and solve problems on their own. In order to counteract this, new standard work competencies for management need to be developed. For example, in a lean healthcare management system, the manager is in the work every day having a dialogue with team members regarding what could go wrong today. Then, together they put processes in place to avoid problems. Asking a simple question such as "who is at risk for falling today?" can result in an entirely different approach to an at-risk patient's care delivery.
HR: The VA mustn't forget the administrative functions in their zeal to implement lean. HR has the role of developing people and providing a safe environment so that people can be redeployed when processes are improved, and a particular job changes or is not necessary. A no-layoff philosophy is critical. If a staff member participates in an improvement activity and their job is eliminated with no options for a new job, will anyone else participate in improvement ever again?
Finance: Finance needs to be part of the team. These professionals are sick and tired of playing the role of cop to operations. They need to be redeployed to the front line management team to help find ways to improve financial performance. They can't do that unless they are freed from the shackles of having to produce a budget every year. Great lean healthcare companies have moved to rolling forecasts as the way to monitor and improve financial performance. This allows for a more accurate prediction of performance and regular updates of critical financial drivers vs. the once a year batch called the budget.
IT: The focus on expensive software has come at the expense of offering good information. Now emerging is the development of clinical business intelligence systems. Clinical Business Intelligence is now allowing organizations to leverage their IT systems to create information flows that are very useful to front line workers. This information can be used to improve care every day.
The delivery of healthcare needs to change significantly. I have briefly outlined some of the changes required to build a culture of continuous improvement. As the Secretary of the VA made clear to the department in July, the VA needs a different strategy to better meet customer needs. That strategy is the lean methodology. There is no need to reinvent the wheel. We already know what the framework for success is.