“By tilling the soil you are making certain your team is prepared for what’s to come.”
- Cindy Rockfeld
One of the most important advancements at Virginia Mason has been learning how to effectively prepare clinical teams for kaizen. One of the concepts from the Toyota Production System that speaks to this need is nemawashi – or “tilling the soil” (laying the groundwork) to prepare clinical teams for change.
Cindy Rockfeld has been leading nemawashi work in her position as administrative director of Ambulatory Services. She says the value is that when the soil is tilled properly before an improvement event, changes are much more likely to stick.
“If the team isn’t ready for the adoption of change, for a new way of doing things, it is very hard to make it work,” she says. “By tilling the soil you are making certain your team is prepared for what’s to come. We till the soil and plant seeds for something to blossom. It’s getting everybody prepared for improvement and change.”
In an organization like Virginia Mason where change is a constant – continuous incremental improvement is at the heart of the organization – preparing team members for change is critical.
As Cindy explains it, nemawashi consists of five components:
1) Standard work for leaders/production board
2) PeopleLink board and team huddle
3) Presence on the genba
4) Team readiness and engagement
5) Leader preparation
“All of these are foundational elements to get teams ready for change,” says Cindy.
Standard work for leaders includes a production board, which we described in a recent post. The board serves as a simple visual marker to provide essential, real-time information about what is happening in a particular clinic or department.
“The production board tells you the lay of the land and lets you know at a glance whether conditions are normal or abnormal,” says Cindy. “It is a visual tool that tells team members where particular help is needed at any given moment.”
PeopleLink and huddles involve getting teams together on a weekly basis so they understand our business (our metrics) and how we are doing (what our patients are saying). Brief daily huddles around the production board help ensure everyone is on the same page with the work at hand.
Genba presence brings leaders at a variety of levels to the front lines where care occurs. “Basically, this involves rounding with teams, asking questions, and being visible so everyone feels comfortable coming forward with concerns, issues and ideas,” says Cindy. “It is really important to be on the genba with team members to see and understand the daily work – as opposed to managing from behind a desk.”
Over time at Virginia Mason, more and more leaders in every department have invested time in genba walks, recognizing that teams truly appreciate leaders who actively lead and guide — demonstrating they truly understand the demands of the work on the front line.
“Our team members do not want leaders who sit in their office generating reports all day,” says Cindy.
Team readiness and engagement involves a practical understanding and recognition that demonstrates everyone’s engagement with implementing change with the tools and techniques of the Virginia Mason Production System (VMPS).
“It’s about the team understanding and engaging with VMPS so they are ready for change. When team members are not engaged with VMPS methodology, implementation inevitably fails,” says Cindy. “But when they are engaged – as they are now – the energy is tremendous.”
Often, one of the barriers to improvement with organizations using a lean methodology is that team members sometimes feel techniques are being imposed upon them. Nemawashi facilitates frontline solution generation. At Virginia Mason, one common method is through the Everyday Lean Idea system in which all team members are encouraged to identify opportunities for kaizen activity.
“That’s why team readiness and engagement is so important,” says Cindy, “It helps make sure all team members, including physicians, play an active role in the improvement process – as opposed to the perception that the Kaizen Promotion Office is imposing change on them.”
Leader preparation involves a leader’s capacity to plan, guide and implement kaizen work. This is part of nemawashi where Cindy says she and her team need the most improvement since she is the only VMPS certified leader who can lead a Rapid Process Improvement Workshop. She and her colleagues are working to get additional members of the team to work their way through VMPS for Leaders training, which provides them with the background and skills they need to lead daily improvement events.
The result of this work is that team members are more engaged than ever. It allows Cindy and her leadership team to lead improvement work that team members are ready for; work that improves productivity and safety, and reduces waste.
“All this work leads to better patient satisfaction because with the team so engaged – with the soil so well-tilled – we are constantly working on changes to improve the department,” she says.
A simple but telling example: The procedural team found that during the three and a half hours patients spent having colonoscopies, 90 minutes consisted of wait time. Cindy and her team pulled the group together and, after a quick Plan-Do-Study-Act (PDSA) during which team members contributed numerous ideas for improved efficiency, lead time (from arrival to departure) was reduced 45 percent.
“All due to team members coming up with idea after idea,” says Cindy. “Our teams are ready for improvement.”