MY TOP 10 LESSONS LEARNEDFROM PRACTICING THE

TOYOTA KATA APPROACH

By Michael LombardMarch 2014

The topic here is lessons I've learned(so far) from my grassroots effort toinfuse the Toyota Kata methodologyinto the culture of an acute carehospital in the Dallas-Ft. Worthmetroplex.

When we began testing the ToyotaKata approach we had no experiencewith or knowledge of it at all, outsideof having read the book a fewtimes. We had no budget to bring inexperts or send ourselves off forformal training.

Context at a Glance

• Acute care hospital in the Dallas-Ft. Worth metroplex

• No prior Toyota Kata experience or expertise

• No budget for consultants or off-site training

• Strong leadership support for continuous improvement

Background…

But, thankfully, we did have senior leader support totry something different; they were ready to investsignificant effort in building a sustainable culture ofcontinuous improvement at our hospital.

We didn't know where the path would take us, but we took astep forward anyway. First, we selected an Advance Team fromdifferent departments and levels of the organization. Then, wedid a tiny bit of home-grown training and quickly got to workpracticing the Kata in the real-world.

How we started…

Now, after about six months of real-world applicationincluding several hundred coaching cycles, I have somelessons learned that I'd like to share...

Advance Team Selected

Initial TrainingPractice & Learning

Sharing Lessons Learned

June-July2013

August-Sept2013

Sept 2013-Feb 2014(& Beyond)

March2014

I always thought a PDSA cycle was when you had identified a countermeasure to a problem and wanted to test it. Well, yes, that is one type of PDSA cycle, but there's more than one kind.

Sometimes, our PDSA cycle consists of nothing more than a quick "go & see" to confirm or deny a hypothesis, without changing or implementing anything at all.

I've come to see a PDSA cycle as simply the act of taking a step forward with the intent of learning something in the pursuit of improvement.

#10 A PDSA cycle is not what I thought it was…

3 Examples of PDSA Cycles

1. Go and See: Direct observation and data collection, without changing anything, to learn more about a process or situation.

2. Exploratory Experiment: Introducing a change in a process to see, via direct observation, how the process reacts.

3. Testing a Hypothesis: Introducing a change, ideally in only a single factor, together with a prediction of what you expect to happen.

Since organizations have many built-in impediments toorganic continuous improvement (annual performancereviews, TPS reports, etc.), we must actively pursuecontinuous improvement through organizational habit-building.

In The Power of Habit, Charles Duhigg explains that fornew habits to form, we must have a habit-building loopin place consisting of a cue, routine, and reward.

#9 Cues, routines, and rewards matter…

Cues• Formal coaching cycles

• Visual signals (e.g. 5 Questions pocket card)

Routines• Improvement Kata

• Coaching Kata

Intrinsic Rewards• Learning

• Solving problems

• Attaining Kata mastery

Toyota KataHabit-Building Loop

The Toyota Kata approach provides all 3 elements of habit-building in abundance

A target condition should always be measureable.However, in the early stages of Kata adoption the focusis more on building habits than producing huge processimprovements with eye-catching ROIcalculations. Therefore, it's advisable to also have away to measure progress in terms of habit-building.

For example, we can track the # of Kata "practitioners",# of Kata coaches, # of PDSA cycles performed, etc. I'lladmit that this is a highly imperfect set of habit-buildingmetrics, so I'm hoping as a community we can come upwith something better.

One option might be to measure what level of skill ourpeople have attained using a standardized rubric, assuggested in some of Mike Rother's online material.

#8 Track the metricsof habit-building…

0

5

10

15

20

25

30

35

40

45

Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14

# Improvement Kata Practitioners by Month

# PDSA Practitioners Added

Cumulative Total # of PDSA Practitioners

0

2

4

6

8

10

12

14

Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14

# Coaching Kata Practitioners by Month

# PDSA Coaches Added Cumulative Total # of PDSA Coaches

0

50

100

150

200

250

Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14

# PDSA Cycles Performed by Month

# PDSA Cycles Performed

Cumulative Total # of PDSA Cycles Performed

0

5

10

15

20

25

Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14

# Departments Utilizing the Kata by Month

# Departments Added

Cumulative Total # of Departments Using PDSA

I think this is because it allows them the freedom to take one bite of the apple at a time. They are free to try a small change or just go get more information, all in the pursuit of learning and iteration. This reduces the fear of failure and the stress of trying to do too much all at once.

It's quite liberating to be able to see the top of the staircase and take a single step at a time.

#7 Clinicians and other front-line staff tend to like the Kata approach.

Current Condition

Target Condition

We've seen great success in using the four steps of theImprovement Kata as a roadmap for fairly large improvementprojects; the 4 routines of the Improvement Kata serve asproject phases, as shown below…

#6 It works on big projects too.

IK STEP 1:

• Understand the Direction

• Sept-Oct 2013

IK STEP 2:

• Grasp the Current Condition

• Oct –Dec 2013

IK STEP 3:

• Establish the Next Target Condition

• Dec-Jan 2014

IK STEP 4:

• PDSA Toward the Target Condition

• Jan-April 2014

We utilized a Steering Team to build consensus for a vision statement, KPIs, 1-2 year goals, etc.

We utilized a cross-departmental team to analyze the current-state via a series of half-day “work-out” sessions.

The cross-departmental team developed the future-state map and built consensus with the Steering Team to obtain approval.

We broke up the future-state map into 6 elements that were assigned to 6 learners who were guided by 1 coach.

The Improvement Kata can be utilized for any type of improvement effort, including big, formal projects. The four routines of the IK provide a nice 4-phase framework upon which we can plug & play whatever project we need.

IK STEP 1:

• Understand the Direction

IK STEP 2:

• Grasp the Current Condition

IK STEP 3:

• Establish the Next Target Condition

IK STEP 4:

• PDSA Toward the Target Condition

This was one of the hardest things for me to grasp as acoach. I almost immediately understood that a targetcondition is not the same as setting a numerical target orgoal; yes, we actually have to describe the future mode ofoperation that will produce the results we seek. This Iunderstood.

What I didn't understand was that describing the futuremode of operation does not require us to know exactly howwe will achieve it. In other words, we don't need a specificlist of countermeasures to be able to describe the targetcondition. In fact, it's better not to lock ourselves into pre-conceived notions of what solutions are needed before we'vebegan testing via PDSA.

#5 Target Conditions ≠Numerical Targets ≠List of Countermeasures

ScenarioNumerical

TargetCountermeasures Target Condition

We want to improve patient safety

10% reduction in medication errors by Q2 2014

• Implement CareFusion barcode scanning

• Switch to new armbands that don’t wash out

• Re-train nurses

A future-state of a highly reliable armband scanning process powered by automation that will reduce the risk of missed armband scans to reduce medication errors by 10% within 30 days.

Here’s a comparison of numerical targets vs. countermeasures vs. target conditions using a healthcare example…

We often think that setting measurable stretch targets will motivate our people to fix the problem, but that’s based on an assumption that a lack of accountability is the root cause of the issue. Where’s the evidence for that?

Too specific. Pre-selecting the specific means by which we’ll achieve the target condition assumes we know what will work prior to testing. Where’s the evidence?

More specific than a vision or True North, but not so specific that we’re left no room to iterate based on what we learn through testing.

I always thought of root cause analysis as a routine weperformed prior to identifying potentialcountermeasures. We'd use 5-Why? or whatever to identify aroot cause, then come up with countermeasures to addressit. What I learned through the Kata approach is that we don'thave to fully understand the root causes of a problem beforewe can start testing countermeasures. In fact, the act of testingcountermeasures (via PDSA) is in and of itself a fantastic way toidentify root causes in an iterative and scientific manner.

In other words, PDSA is an empirical approach to root causeanalysis, that can be utilized alongside statistical and practicaltechniques…

#4 Root cause analysis isan iterative process.

• Regression

• ANOVA

Statistical Techniques

• 5-Why

• Ishikawa Diagrams

Practical Techniques

• PDSA Testing

• Design of Experiments (DOE)

Empirical Techniques

Find the right mix of statistical, practical, and empirical rootcause analysis techniques to keep the “batch size” of your RCAwork at an appropriate level to reduce the risk of errors inyour analysis…

Even though the Coaching Kata provides clear instructions on what questions to ask (the 5 Questions), novice coaches typically struggle with how to stick to the script without being too robotic and awkward about it. It's a balancing act. A Coach must be able to sense when the Learner is in need of strict structure (new learners often go off in ten directions at once and need to focus on the single next step) and when a more creative, free-flowing discussion is appropriate.

#3 Coaching is tricky.

Practical Coaching Tips

1. Don’t kick-off a coaching cycle w/ the 5 Questions: break the ice first to make the Learner comfortable.

2. Utilize visuals: always have the 5 Questions pocket card, 5 Routines placemat, etc. on-hand as teaching tools and visual cues for routines.

3. Expect awkwardness: it’s okay to admit that following a “script” can be awkward at first. Get it out in the open early in your engagement.

4. Go off-script: it’s fine to meander during a coaching cycle in order to introduce a new tool just-in-time or to tell a story to spark the creativity of the Learner.

Mastering the Kata is mostly a learning-by-doing effortthat relies heavily upon repetition and deliberatepractice. The Coach should foster an environment thatallows the Learner to practice and fail (and trust me, inthe early going most of the practice results infailure). Because 'practice' in this context occurs in thereal-world (not in some classroom simulation), thesefailures must also be done in a safe manner that causesno irreparable harm or embarrassment.

The Learner’s target condition has an achieve-bydate, and that target condition is where the benefitcomes from. Don’t fall into the trap of thinking thateach step along the way should provide a benefit!

#2 Coaching means providing a safe environment to fail.

“I have not failed. I've just found 10,000 ways that won't work.” ― Thomas Edison

Fortune favors the bold.

How to get started?1. Get a group of leaders passionate about continuous

improvement and get them to read and discuss Toyota Kata with you.

2. Form an Advance Team of folks from different departments and levels of the organization and have them shepherd the overall deployment.

3. Find a sensei, someone who can “coach the coach” to help you get started.

4. Train up the Advance Team as best as you can and start practicing the Kata routines (prepare to make mistakes!)

5. Once you reach that target condition, you’ll know what to do next!

#1 When in doubt, take a step forward and reflect!

Michael Lombard is a seasoned leader in healthcare performance improvement. His mission is to help healthcare systems deliver ever-increasing value to patients and the community by improving quality and reducing cost. His approach is to get results by facilitating process improvement while increasing the improvement capabilities of the people in our organizations, in an effort to build cultures of continuous improvement.

His goal for writing is to explore ideas and continuously improve his understanding of kaizen in healthcare settings.

Please feel free to contact Michael…

@MikeLombard LinkedIn mlombardjr@gmail.com

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