“You’ve got to live this every day and if you think it’s just an another initiative that you can kick off and then step back and have the consultants or the team underneath you lead it, you’re wrong.”
– Sarah Patterson
During the past dozen years, Virginia Mason has become one of the world leaders in adapting the Toyota Production System to health care, and Sarah Patterson, executive vice president and chief operating officer, has been a leader there every step of the way.
Her reflections on the lean management system are particularly insightful. Among the countless essential lessons she has learned through the years is that as a leader you must be engaged in the improvement work every day.
“As a leader, you’ve got to live this every day,” she says, “because what you are doing is changing the culture of the organization by changing the behaviors of the leaders. If you think you can stop leading the weekly report-outs on improvement work or stop doing genba walks to see what is going on in the organization or say that executives don’t have to be certified lean leaders anymore because they are too busy, and because we’ve come so far, you’re wrong. If you start backing down, if you acquiesce on important commitments you have made as leaders − which really make up the structure and discipline of the management system and require that leaders be coaching and mentoring on the front lines of the organization − you’ve lost.’’
Early on, Patterson learned that many health care team members suffered from a kind of improvement fatigue. They had seen a variety of improvement projects or methods tried and abandoned – derided as improvement project “flavors of the month” − and had no real belief that the adaptation of the Toyota Production System would be any different.
“They didn’t know what a management system really was and even we, the leaders, didn’t know what it was but we knew enough to know we would be more able to execute on our vision and strategy with one,” she says.
Some skeptics were loud and difficult, while others were more subtle. Patterson recalls, “People would tell me they were waiting to see if we would blink and if you did, they’d say, ‘OK, we knew you weren’t serious about it.’ Staff members would tell me that they were waiting us out. One person told me, ‘I’ll give you two or three years, Sarah, and then if we’re still doing this, I’ll believe it and I’ll get on board.’”
A dozen years later, just about everybody at Virginia Mason is on board. That has created an alignment throughout the organization that enables continuous improvement. In many organizations it is common for department heads to fight for resources for their team, to focus on the work of their department with little thought to overall organizational goals.
It is different at Virginia Mason. “Starting years ago we had conversations about how we as a leadership team need to be aligned around this management method and around our goals,” says Patterson, “and how this wasn’t about each of us individually deciding we like this or not; we are one team working together on the entire body of work and that is what we do and over the years we have refined that.”
“At Virginia Mason all the executives are responsible for all the goals,” she emphasizes. “I’m not just responsible for the goals in the areas that report to me. All leaders are responsible for all our goals, and our compensation is based not on how we perform individually but how we perform as a team on our overall organizational goals.
“Every Tuesday when we go to standup we’re looking at each other and saying, ‘what are we doing to keep this work moving?’ And if the status is that it’s not on track, ‘OK, what do we need to do? Who needs to be engaged?’”
This is where having a World Class Management system comes into play, for it is the processes and procedures that ensures an organization can accomplish its goals. World Class Management has three components:
- Management by Policy, which means having focus, direction and alignment within the organization through a goal-setting process that engages everyone;
- Cross Functional Management, which calls out work that goes across the organization and aligns everyone toward full customer satisfaction; and
- Daily Management, which is essentially standard work for leaders, the daily routines and behaviors of leaders from a frontline supervisor to an executive that create the environment and ensure reliability of processes day in and day out.
Daily Management has become a particularly important strategy at Virginia Mason. In practice, this approach means “leaders have two important jobs – running their business and improving their business, and they are right there side-by-side with staff doing the work,” says Patterson. “It’s about working with people in a respectful way so they have the opportunity to identify the problems we need to fix through root-cause analysis. Then, for me as a leader to be right there asking questions, helping to be sure there are the resources to fix them. It isn’t the leaders that are deciding what to work on, it’s the people who do the work because they know what’s getting in the way of providing great care to our patients.”
Daily Management is critical to strengthening standard work and reducing variability in day-to-day processes. A huge part of leadership at Virginia Mason is making sure standard work is developed and being followed consistently for the benefit of patients.
“This is what most organizations struggle with the most: how to ensure the improvements they have made are sustained,” Patterson says. “Without leaders regularly checking to see if they are still in place and signaling that it is important to follow the new standards, it is easy for things to drift back to everybody doing it their own way.”
When Patterson is on the genba seeing the reality of the current state in the hospital or clinics, “I’m looking to see if I can see the standard work in place,” she says. “The idea is not just to get a report from the person who reports to you, but to literally be there on the genba watching and looking, coaching, teaching. As an executive leader, I should not be just relying on my team to tell me what’s going on but I should go out and see for myself.”
Daily Management means that not only are leaders following their standard work, but that the notion of sticking to standard work is cascading down to all levels of leadership. Managers, for example, may be checking on standard work at least weekly and perhaps even daily. And Patterson says that at a supervisor level, “supervisors check in with their frontline staff on an hourly basis in some cases. Supervisors may round three or four times a shift, and they are continuously pitching in guiding, responding to questions and concerns.”
Ideally, if Daily Management is in place and all leaders are doing their jobs, then Patterson says you should be able to see what any work unit does, whether it is on schedule, and more. “This is really how the culture shifts from those days of heroic action in health care – I call it management by superheroes, which is a dangerous way to provide care – to reliability and calm and providing great care every day,” she says. “Leaders often get to where they are by being good crisis managers, and now we are saying that a crisis is really a failure of leadership.”
A great deal of progress has been made through the years, but Patterson and many of her leadership colleagues have a mantra of sorts when they are asked about the progress. Yes, she acknowledges, there has been progress, “But I know we have huge potential to do better. All I have to do is go talk to our team members and they will tell me all of the opportunities we have to make things even better. The great thing is that they aren’t waiting for me to make the improvements, they know how to do it themselves.”
As a leader, how do you show your team that you are “all in, everyday?”