I want you to think about the term Leadership for a moment. If I asked several of you to give your definitions I bet there would be many different points of view, some similar, perhaps, but most quite different. Do you envision someone who is strong and demanding with rigid concepts about getting things done? Do you envision someone who is a good listener, who leads by example? I think there are many valid ideas about leadership, and each probably has its place depending on the situation. I want to focus on what kind of leadership is necessary for changing an organization into a Lean organization or maintaining a Lean organization. The reason I choose to do so is that I am a member of a committee that is charged with developing a program to assist local physicians and physician organizations incorporate Lean healthcare with the Wagner Chronic Care Model. One of the milestones is to develop leadership locally; leadership in quality also came up as the primary identified need in a survey of the local physician organizations.
When changing an organization into a Lean one, the first thing I consider is the person at the top and his characteristics. Without firm support from this person the transformation will not be successful and will not endure. In a hospital this would be the CEO and in a primary care setting, the person making the major management decisions, whether the office manager of a physician. One characteristic of this leader should be persistence. Why? Changing the way an organization approaches quality requires a cultural change. Such change will encounter resistance; people tend to resist change because maintaining the status quo is comfortable. A leader at a hospital, for instance, might after much staff training in Lean tools succeed in getting the front line workers-the nurses, the aides and the doctors--to change only to have middle management sabotage the efforts. Only with persistence can this roadblock be overcome. Persistence mixed with patience and high standards will be necessary because the changes will take a considerable amount of time too. One year for a primary care office to embrace continuous quality improvement would not be unusual, whether the leader starts small by changing one part of the office at a time or whether the staff as a whole is trained and asked to change. By the way, in a November 19, 2007 article in the Wall Street Journal persistence along with attention to detail, efficiency, and analytical skills were named as the most important skills of successful CEOs.
CARE IMPROVEMENT
Attention to detail means recognizing and understanding how the parts work together. In order to lead change successfully this would mean understanding how different members of a quality improvement team work together. Do they complement each other? Do they clash? The leader is responsible for integrating such a team. Besides understanding team dynamics, a leader must understand how the different parts of the healthcare site function. Does the support staff or administration complement the clinical? For instance, is billing efficient? If not, this has negative consequences in providing clinical care.
Efficiency in quality improvement cycles means understanding where waste exits in an organization and also understanding how to utilize staff ideas to eliminate these wastes. For example, in a primary care site a leader should have a clear picture of how to reduce the time spent looking for misplaced patient histories, if paper histories are still being used. Of course, if electronic health records are being used, this problem would be largely obviated.
A fourth skill very necessary for strong quality improvement leadership is analytical skills. A leader should be able to weigh the cost of a quality improvement effort versus the return on investment. Rarely are the success or failure of a quality improvement effort tracked in terms of cost and savings. Focusing only on patient health means that sustainability is ignored. With the increase of competition in health care and the advent of bundling of payment for services in Medicare the financial factor cannot be ignored.
Besides these four characteristics the leader guiding the Lean transformation must also understand some of the basic tools of Lean-process mapping, kaizen events, 5S and voice of the customer, among others. I don't think that the leader needs to be the master of these; rather she should be able to recognize their correct application and through her vision of a quality organization see that these tools are implemented and the results communicated throughout the organization. One situation, for instance, in which the leader makes sure the tools are implemented correctly is by appointing people with Lean skills to teams; this team might be defining new processes to handle diabetes patients in a primary care setting. She should be able to select an able leader for this team and see that the ideas generated are sorted and disseminated with the best ones implemented. Once the process is implemented the leader should have the impact measured and if the impact is positive have the process maintained in spite of common roadblocks such as resistance from those who want to maintain the status quo, as mentioned above.
In order for a leader to become familiar (not an expert though) with these tools several approaches are possible. There are many conferences and trainings for lean management available in healthcare. The American Society of Quality offers such. Another approach is to contract with a consultant who is familiar with both healthcare and Lean techniques. Whatever the approach-workshops, conferences, online training or hiring of a consultant--I think it a good idea to follow up these with a reference text such as A Lean Guide to Transforming Healthcare by Thomas Zidel.
Lest you think that I miss the mark with my characterization of a Lean leader, let me relate one last story. Jaimie Houghton was the CEO of Corning Glass and implemented Total Quality Management in the early 90's to Corning. He spent a great deal of time traveling to Corning's units worldwide to drive his vision of a quality organization. In 1995 one of Corning's units received the Malcolm Baldrige National Quality Award. Mr. Houghton retired the next year after successfully imbedding TQM in Corning. His successor, however, did not have the passion for quality that Mr. Houghton had. The programs were not abandoned but other priorities and visions preempted Mr. Houghton's legacy. The result was that sales dropped dramatically and the stock price fell from 3 to as low as .10. In 2002 Mr. Houghton was coaxed out of retirement to rescue this failing giant. This time, Mr. Houghton instituted quality using Lean and Six Sigma. He made sure that the programs would endure after he left again. Although the share price is considerably below the high of 3 of previous years, the company leads its competitors considerably in market value. Much of this is attributable to the persistence of Mr. Houghton in ingraining recognized quality approaches into the company.
Characteristics of a Successful Leader in a Health Care Setting CARE IMPROVEMENT
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