Lean Leaders Wanted!

'Go to the people. Live with them. Learn from them. Start with what they know. Build with what they have. But with the best leaders, when the work is done, the task accomplished, the people will say "We have done this ourselves." ' —Lao-Tsu, founder of Daoism

There are leaders and then there are lean leaders. What's the difference and why are they better?

Lean leaders create a culture where change is embraced as an opportunity for improvement and innovation. People are natural problem-solvers and the lean leader increases this skill with lean management. Lean leaders use their authority to manage people in the following methods:

  • Create a shared vision: By creating a shared vision the lean leader is able to align goals so that both the work and the people grow together. This shared purpose creates momentum while empowering the team to problem solve their issues together and form a healthy social bond.

  • Bottom-up management: A major difference in this management style from that of the atypical Western leadership style of top-down is that the lean leader believes the people doing the work are the best at figuring out how to do the work. A lean leader does not seek to convince or demand others to do things their way; instead they provide a safe space for inquiry and experimentation to challenge the team to find out what works best.

  • Guiding by challenge: The lean leader challenges the team by asking questions to evoke problem solving skills and idea sharing within the nurturing environment of the team where processes not people are judged. These challenges are meant to be part of their development and growth in themselves and their work. The work is a moving target and the lean leader ensures the work environment is non-judgmental to allow for innovation toward ultimate efficiency.

The effect of lean leadership is that there is one organization and one vision to continuously improve the processes within the organization while improving themselves. Are you willing to be a lean leader? If yes, you're wanted! Please contact us to learn more of this management style and how the Infinitum healthcare transformation system can improve your organization!

Work Cited

Lao-Tsu Opening Quote: https://www.accessengineeringlibrary.com/browse/toyota-way-to-lean-leadership-achieving-and-sustaining-excellence-through-leadership-development/c9780071780780ch07

How do the Toyota Production System and Healthcare Connect?

Patients are not widgets and healing is not a production line. So how do the Toyota Production System and Healthcare connect? Read on to find out how!

Lean Management History

The history of the lean concept grew out of the Toyota Motor Company established by Sakichi Toyoda in 1935. In 1950 Eiji Toyoda and Taiichi Ohno studied Western car production because the Japanese output was far less than the US output. Ohno observed two major flaws: large batches that created large inventory, and manufacturing methods that preferred large production over customer preferences. Through observation and small incremental changes the Toyota Production System (TPS) was created to make Toyota a world class auto manufacturer. How did they do it? They utilized the lean principles to manage production, employees, and even suppliers.

Lean Management Connection to All Industries

In 1990 the book The Machine that Changed the World coined the term "lean" production. The authors, Womack, Jones, and Roos, did a 5-million dollar 5-year study and postulated that the manufacturing and technology problems are universal to all of business management. This "transference" of issues meant that by "extension" the same lean principles that were successful for Toyota could help other organizations outside of the non-Japanese enterprises. According to Womack, et al, Western manufacturing companies quickly incorporated five lean principles into their processes:

  • Identification of customer value - the customer, or patient, determines: what is value and what is waste? For example, a patient may think it a waste of time to be sitting in the waiting room for more than 15 minutes. (There are eight defined wastes: motion, unused talent, inventory, over production, transportation, defects, over processing, and unused creatity.)

  • Management of "value stream" - there are four value streams (demand management, care delivery, financial viability, new service development & quality improvement) to be managed in balance of each other.

  • Developing capabilities of flow production - a lean environment is a learning environment where front-line employees are innovators and creators of change.

  • Use of "pull" mechanisms to support flow of materials at constrained operations - the lean mindset looks to find opportunities to keep the patient moving through the system.

  • Pursuit of perfection through reducing to zero all forms of "waste" - this is a continuous quality improvement process that is accomplished through the knowledge and utilization of lean methodologies.


Lean Management for Healthcare

To answer the question: how do the Toyota Production System and healthcare connect? They connect because every industry, including healthcare, is producing something that needs to be managed as efficiently as possible. And that something can be made more efficient by the lean principles and methodologies of lean management that will create a new paradigm around a bottom-up problem solving mindset where waste is removed to create more patient value and practice harmony along with increased demand capacity. What are the people at your healthcare organization producing?

Works Cited

Teich, Sorin T. and Fady F. Faddoul. “Lean management-the journey from Toyota to healthcare” Rambam Maimonides medical journal vol. 4,2 e0007. 30 Apr. 2013, doi:10.5041/RMMJ.10107 Web address: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3678835/

Womack, James P, Daniel T. Jones, and Daniel Roos. The Machine That Changed the World: Based on the Massachusetts Institute of Technology 5-Million Dollar 5-Year Study on the Future of the Automobile. New York: Rawson Associates, 1990. Print.

Best Professional Investment or Accomplishment by Healthcare Leaders

In an article published in Becker's Hospital Review regarding the best things a healthcare leader did for themselves, their careers and/or their organizations, ten healthcare leaders shared their answer that interestingly aligns with the Infinitum Healthcare Transformation System:

1. Consumer-focused marketing utilizing more research and data driven decisions.

Infinitum will research the entire healthcare organization through surveys, interviews, and assessment tools to create data driven decisions as to the readiness of the work that needs to be done, where there is opportunity for the most benefit for quality improvement, and the best ROI to increase capacity and revenue including possible new service lines.

2. Touching & treating patients as front-line leaders.

Analyzing process and not people, Infinitum consultants work with the front-line staff as they are best positioned to redesign and improve care. Infinitum uses their knowledge of the work area to create collaborative improvements across the organization as a system.

3. Toyota Production System as a management system.

Infinitum methodology includes Toyota's lean thinking as a philosophy that aims to enhance operations through continuous process improvement, standardizing processes, and eliminating waste. This allows an organization to improve patient safety and care, and improve efficiency and capacity. This change in thinking creates a flexible culture of change and utilizes your staff more wisely.

4. Recognizing the need to surround myself with those wiser than myself.

Infinitum Consultants are lean subject matter experts that will assist leaders to promote a consistent day-to-day approach to implementing process improvement across an organization in order to achieve sustainable results and a collaborative culture in the work environment.

5. Always asking "what is best for the patient" across the entire patient experience.

This question is foremost in the Infinitum philosophy of transformation. One of the lean tools that a consultant will teach to employees is an A3. An A3 is an organized-living tool to identify, record, and implement standardized change across the entire patient experience.

6. Intense focus on improving the patient experience.

Analyzing the current state of this experience, identifying issues, finding the root causes, and implementing counter measures to create a future state provides a comprehensive look at the patient experience from their view.

7. Watching my peers grow and being a positive influence for them.

Infinitum University and Infinitum Toolset both provide the knowledge base and experience to influence positive change for the people you lead and the organization you serve.

8. Evidence-based practices resulting in excellent clinical outcomes for patients

Infinitum can provide a comparative performance metric database. Within the 8-step Infinitum system there are pre and post assessments that can provide a baseline and comparative data to other organizations.

9. Recognition of quality care.

Infinitum certification is based on the completion of Infinitum University and lean methodology attestation of process adoption. The courses are online for convenience and can be administered at three levels: employee, organization, or both. The employees and the organization will be recognized as quality improvement professionals within a fully efficient certified healthcare system.

10. Assisting other organizations to transition from volume to value-based care.

The Affordable Care Act has changed the way healthcare systems bill for services. This required change has forced practices to look at how they manage and balance care delivery, demand and capacity, financial viability, and new service development along with quality improvement.

Infinitum is the best investment that will assist healthcare professionals and organizations accomplish their goals. Contact us to find out how it can work specifically for your organization!


Work Cited

Becker's Hospital Review. 2018. August 10. Gooch, Kelly. Website Address:  


How can Infinitum help you gain work-life-balance in 2019?

As much as we all want to think that our work life does not affect our personal life, it does. A study funded by the American Medical Association and published in the Annals of Internal Medicine found that "1 to 2 hours of personal time each night [was spent] doing additional computer and other clerical work." I offer an empathetic and rhetorical, "Why?" 

The New Year brings new energy and thoughts of improvements for our lives. How can we be healthier, wiser, and financially better off? In our personal lives, we might be thinking about exercising and eating healthier; working on our relationships; simplifying our lives; and saving more money for investing. In our work lives, we might be thinking about how to reduce the workload; how to minimize stress; how to manage work relationships; and have a better work-life balance. In the same study mentioned above, data showed that "for every hour physicians provided direct clinical face time to patients, nearly 2 additional hours is spent on E.H.R. and desk work within the clinic day." As dedicated professionals you look to give your patients the best possible care, and still complete all the other required tasks. Is there a process manual on how to achieve that and have work-life-balance? Yes, and it is called Infinitum! 

Infinitum is a lean transformational healthcare system for practice management that can provide the change you are looking for in your work life and the practice processes. Through lean management assessments and tools, a team of Infinitum consultants will work with you and your staff to bring about the desired changes, increase capacity, and create a team mindset for continuous quality improvement that is sustainable. As healthcare reform transitions to the value based payment model, Infinitum can drive performance measure improvements. Let us show you what Infinitum can do!


Work Cited

Sinsky, MD, Cindy, et al. Annals of Internal Medicine: "Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties" https://mfprac.com/web2018/07literature/literature/Misc/MD-Time_Sinsky.pdf

Infinitum Practice Management and Transformation

Infinitum is the practice management and transformation system from VPQHC. It has been designed from the ground up to allow practices to focus on delivering care in the most effective and efficient ways possible. A comprehensive, yet flexible system allowing "ramp up" activities such as individual improvement projects all the way to full scale practice transformations over multiple years, Infinitum rewires your practice at operational and human levels to enable permanent change. 

We've been working on our Infinitum practice management and transformation system to bring it to market in the very near future. Infinitum consists of four elements:

  1. The Infinitum management and transformation methodologies
  2. Infinitum practice coach training and certification
  3. Infinitum certification for practices
  4. The Infinitum practice business process comparative database

Responding to demand, we have accelerated development and launch of Infinitum University, our online learning environment which will administer and provide training courses in the Infinitum methodology. Our first courses will be available in the next couple of months, so if you are interested in discovering more, please email us at leeb@vpqhc.org I'll be happy to talk about the various options for training and development within the Infinitum system. Watch this space for further updates soon!


New Year, New Approach?

As 2016 drew to a close, the political environment in the USA was turbulent. In an atmosphere of disinformation as the norm, establishing clear pathways for the continued evolution of the health care reform efforts instigated by MACRA is proving ever more difficult. We simply don't know what the effects of this sharp political direction change may be, and that only fuels the uncertainty felt in the health care system as a whole. 

What we do know however, is that the basic premise of the health care reform movement in the USA is unchanged. The system as it is currently configured is inherently flawed, the net result of those flaws being the double digit increases in health insurance premiums we have been seeing for the last few years. This situation is as unsustainable now as it was in 2016, and so the rationale behind MACRA remains the same too. The House and Senate realized this and backed MACRA in a bipartisan manner. Since then some of the provisions have been enacted and now the implications are beginning to be felt throughout the system. This is the equivalent of the supertanker changing course, but instead of physical momentum taking the ship 10 miles before being able to execute a turn, we have political momentum driving the system forward, but with the course corrections inherent in MACRA slowly turning the system to a new direction. This takes progressive time, unless a tipping point is achieved whereby the desire for change overcomes the threshold level of resistance forces against it. I can feel that tipping point rapidly approaching. 

What does this look like at each level in the health care system? Clearly there are some themes that are relatively constant. Costs are increasing, demand is increasing, supply (of qualified providers and associated resources) is decreasing and wages are stagnant. Whichever level you work at, the net result of these factors is increasing pressure to understand your costs, how they arise and how you can reduce them. In a system that has shown little appetite for exposing those costs, this pressure begins to stress the system as a whole. That stress rails against the system constraints, such as politico-economic forces, resulting in decreasing performance, an exodus of trained providers exacerbating the already diminished pool and more patients postponing or neglecting to engage with the system in anything other than catastrophic ways (typically by presenting at the ED). 

Systems thinking teaches us to look at the root causes of system conditions and address them to achieve sustained improvements in performance. Identifying and working with organizations to improve these conditions is a core specialty at VPQHC. Email me at leeb@vpqhc.org if you would like to find out how we can assist you to get an understanding of your costs, a plan to improve them and sustained assistance in implementing those plans. 

Where do I find the time to do all this?

In my work with medical practices, hospitals and other organizations there is one almost universal issue that arises, seemingly to stop any progress dead. 

"How am I supposed to find the time to do all this? My practice is already swamped with work, we're not getting home on time, staff are frazzled and now you're telling me I need to develop a Vision and Aims for it? I don't have the time right now. Sorry."

My reaction is always the same. From a systems thinking standpoint, the system is perfectly engineered to produce the results it is producing at any given time. If the results show stress in the system, there are clearly difficulties within the system that lead to this stress. Without addressing the root causes of this stress, the system will continue to exhibit these characteristics and life as we know it will not change. It is a self limiting system, and without breaking from the cycle of acceptance of current conditions, the system will not change. 

Breaking from the cycle of acceptance requires two things:

  1. An understanding of the situation 
  2. A commitment to perform an action to solve something. Anything that will release capacity that is currently being consumed in wasted activities. 

Understanding the situation requires the ability to see the system itself. This is where the services of an experienced practice coach can be invaluable, as they are skilled in helping owners change perceptions and see systems differently. Once the situation is fully grasped, making a commitment to release currently consumed capacity can occur. The specific business process to work on to release the capacity is of course completely dependent on current circumstances and should be evaluated with the practice coach. 

It cannot be stressed enough how important this first step is to a successful transformation. Proving that capacity can be released by reconfiguration of business processes is the key to unlocking more activities and eventually, full system redesign and transformation. VPQHC is experienced in this work and can help take your practice to performance levels which will enable it to thrive in the new value based payments structures currently being introduced by CMS. If you would like to find out more, contact me at leeb@vpqhc.org for an introductory discussion. 

MACRA and MIPS and APM's - oh my!

Part of our work at VPQHC is with the Northern New England Practice Transformation Network (NNE-PTN) working with practices to help them transition their operations to be more successful in the upcoming value based payment systems such as Advanced Alternative Payment Models (AAPM's) and the new Merit Based Incentive Payment system (MIPS). We use a transformation methodology from CMS called the Transforming Clinical Practices Initiative (TCPI) which examines a practice within 27 distinct domains, evaluating the maturity level of each domain and producing a structured action plan to take those domains to their next stages of maturity. It's a complex process, and takes significant time, which is why the typical TCPI engagement lasts four years. 

The Medicare Access and CHIP Re authorization Act of 2015 (MACRA) mandated CMS with producing the MIPS system to replace the PQRS, Value Based Modifier, Meaningful Use and Resource Utilization Index measures, and produce one integrated system to be a "catch all" for practices that are not joining an advanced alternative payment model such as an Accountable Care Organization (ACO). (Practices joining ACO's have their own criteria and system to ensure they move to value based payments.)

The time line for these changes has caught a lot of practices by surprise. The first reporting year starts Jan 1 2017 (in about 6 weeks) and many practices either do not know of these changes, or are doing very little to change their operations to work within the new system.  MIPS has provisions to impose positive and negative modifiers on medicare payments, beginning with +/- 4% in 2019 (based on 2017 results) and up to +/- 9% in 2022 (based on 2020 results). If your practice has significant medicare billings, these figures will start to impact your financial performance starting 2019. 

TCPI is designed to help you navigate MIPS, submit data to CMS appropriately and design your operations to more effectively produce value, which is reflected in the MIPS scores. For any practices that are not currently in an advanced alternative payment model, a CMMI demonstration project (such as the Blueprint for Health in VT) or other CMS funded program, TCPI offers 3 years of free technical assistance to help you configure your practice to succeed in this new environment. In VT we currently have 22 practice slots available for the TCPI program. If you would like to discuss options, please don't hesitate to contact me at leeb@vpqhc.org

"Infinitum" Practice Transformation

At VPQHC we cover the whole spectrum of healthcare in Vermont, and increasingly the whole care continuum as the United States begins to change thinking in this area to embracing the social and behavioral determinants of health. As the only neutral healthcare quality organization mandated by statute in the state of Vermont, we take our role in guiding the development of the statewide healthcare quality system very seriously. 

Primary Care and Specialty Practices have been historically under served with high quality, independent assistance in their operations, strategy and growth pathways as they struggle to adapt to the rapidly changing world of value based compensation from the traditional fee for service world. Recognizing this, we took a long hard look at the needs of this sector, matched it with our broad and deep experience and expertise bases and developed a practice transformation center of excellence. 

"What's a practice transformation center of excellence?" Well, we have been the Vermont partner in the Northern New England Practice Transformation Network for over a year now, assisting practices across the state (and in NH) with their efforts to transform their structures and operations to better live in the changing reimbursement environment of MACRA and MIPS. We have been instrumental in refining and extending the Transforming Clinical Practices Initiative (TCPI) methodology into a system that truly guides the practice to a higher performing state. In addition to this, we have taken our own experience bases and extended our practice transformation system far beyond that in TCPI to a truly holistic system capable of taking any practice from struggle to supreme performance. We call it the Infinitum Method because the scope of improvement is limitless with the right guidance and coaching. 

Over the coming months, you'll begin to see more about this in our materials, communications and events. As we launch educational and service offerings, we will be in touch to get your feedback and discuss opportunities for us to work together to truly transform your practice. If this is something you would like to find out more about, please call us on (802) 229 2152 or email me at leeb@vpqhc.org