In 2011, Los Angeles County’s Registrar-Recorder/County Clerk, Dean C. Logan, had a vision of his department becoming a leader in customer service.  He chose to use the methodology of Lean Six Sigma to help make that vision a reality. A six member team was formed and given the green light to look at one process in each of its four Bureaus.

With the guidance of Lean Six Sigma consultant, Tracy O’Rourke, the team, along with line staff from each operation, eliminated unnecessary steps, reduced wait time for customers and provided a cost savings to the department. An added benefit from these improvements was watching how line staff proudly took ownership of their part of the operation. News that the staff had a input on what changes were made lit a spark that spread like fire among dry brush. Supervisors like Darla Neal, of the Business Filing and Registration section, took the initiative to request the support the Lean Six Sigma team to improve processes in her section. We will take a look at how she was able to answer the call for change.

What the Registrar-Recorder/County Clerk Does

Los Angeles County services its 9.8 million residents in many ways and its leaders are constantly stressing their vision of providing excellent customer service. The Registrar-Recorder/County Clerk (RR/CC) is one of 37 departments in the County. It is responsible for conducting various elections, providing birth, death & marriage certificates, real estate records, business filings and voter registration applications. Each year the office conducts approximately 200 elections for schools, cities and special districts for the 4.1 million registered voters in the county.

The RR/CC also issues approximately 75,000 marriage licenses, 2 million real and personal property documents, 750,000 birth, death and marriage records, and processes 125,000 fictitious business name filings annually and services approximately 2,000 customers on a daily basis. Department Head, Dean C. Logan, prides himself in staying in line with the County’s vision. He has developed a mission statement for the Department: “Serving Los Angeles County by providing essential records management and election services in a fair, accessible and transparent manner.” With this in mind, in March 2011, Mr. Logan sought out a reputable process improvement program that could assist the department in improving their processes which in turn would improve customer service. Six staff members, from different operations of the department were chosen to train and become certified in the Lean Six Sigma (Lean Six Sigma) approach.

As a part of the training process, the Lean Six Sigma students were required to choose a project that they would like to improve. At Mr. Logan’s suggestion, the team members focused on four real operations within the department. Once the certification process was complete, the Lean Six Sigma team returned to the department eager to get started. After hosting a Lean Six Sigma introductory session for management staff, the team members, along with the Lean Six Sigma consultant was now ready to tackle an actual program. It is important to always include management in your introductory meeting. You need their buy-in in order to make this improvement process work. You also want to emphasize that the Lean Six Sigma team will work hand in hand with the line staff to come up with suggestions but will not act until they have given the go ahead.

Change Is Addictive

The process improvement successes from the initial four projects received not only internal recognition but external as well. By eliminating unnecessary steps and reducing processing time, The Vital Records Mail Processing Unit and Lean Six Sigma team received Stars Award. This is a prestigious honor given by The Los Angeles County Board of Supervisors. As the idea of process improvement started to spread in the department, Section Heads like Darla Neal began to look at their own unit and how their operation could be improved upon. Ms. Neal supervises the Business Filing and Registration (BFR) section. What is BFR you might ask, well within 40 days of starting a business in Los Angeles County, it is the responsibility of the business owner to register and file their fictitious business name with BFR.

It is then the responsibility of the BFR clerk to ensure that all paper work related to filing is properly completed and legally bonded under the Business and Professions Code. The supervisor noticed that approximately 55% of the applications received in a week were being rejected. These rejections had to be mailed back to the customer, at the expense of the department, and re-filed, causing the customer a loss of time. Just think of all the time and cost lost with the department receiving about 125, 000 applications per year. Although many Lean Six Sigma projects begin with trying to identify the problem by conducting a GEMBA walk, the Japanese term for “walking the process,” that was not necessary in this case. The supervisor knew that the problem was “too many rejections” but needed help in finding the solution.

Getting To The Root Of The Problem

When the problem is already known you can move directly to discovering its root causes. To get to the root cause of the numerous rejected applications, the team conducted what is known in the Lean Six Sigma world as a Kaizen Event. Kaizen is another Japanese term that allows you to tackle specific, focused problems and barriers. This involves a team of people who either work in the area where the problem exists, or who are directly or indirectly affected by the activities in that area, this was the BFR staff. The work group was formed; it included the Lean Six Sigma team, the immediate supervisor and five line staff, one from each part of the operation.

By having each area represented all bases could be covered and input could be received from every aspect. A two day session was held in order to look at all facets of the “rejection” process and the brainstorming began. During the Kaizen brainstorming event the full team came together and started listing what they believed to be some of the factors that caused an application to be rejected. Keep in mind that at this point the Lean Six Sigma team were basically there to lead and guide the session, it was the line staff that were encouraged to give their opinions without any accusations or blame. This is key to having the participants feel comfortable and safe to share all their thoughts, there must be a “blame free” environment. When trying to get to the root causes of a problem a Fishbone Diagram is a great process map to create (see chart below).

As you can see, the diagram actually looks like the bones of a fish. The fish head is what stinks, this is the problem or the undesirable effect or in our case the “rejected application.” The four ends of the bone were identified, administrative and customer issues, the actual form and the web site. These four tips are what the line staff considered as the main contributors to the problem. Once the bones are established you can then begin adding the smaller bones (errors) that are associated with the main tip. What worked best for our team was to break the line staff up into four groups with a Lean Six Sigma team member in each group, each group focused on the issues involving one bone. Once all the contributing factors were listed, we then began to discuss what issues could be attacked immediately and which ones would take more time and research to resolve. Because the “rejected application” process had so many suspected contributing factors, the Lean Six Sigma team recognized that they needed to start by “Shrinking the Change.”

We knew that a succession of small changes could lead to a big change. The issues that could be addressed and corrected immediately are called “Quick, Quick Hits.” Then there are the Quick Hits, these might take a little longer to fix or have other contributing factors attached. Next are the Long Term Action Items, these can sometimes require legal action or can be looked at again after some of the other changes have been made and have a ripple effect on the long term item or they might somehow be linked to the quick hit and eventually be changed. Keep in mind that any suggested change should be reviewed by management. They are the ones to give approval and would know if any of the changes would affect policy or service to the customer.

In the case of the “rejected application” the line staff identified 9 reasons that an application might be rejected. Each team member took one or two issues, along with an Lean Six Sigma team member, and set out to find a solution. Anyone from the line staff that is willing can lead the project, just remember to keep a record of the dates when an action item is completed (see chart below).

When you begin to discuss each issue in more detail you will begin to notice that not everything listed can be changed, some processes are there for a reason. It could be a legal matter or maybe even an administrative policy. Whatever the case don’t get discouraged, work on the issue that you can change and count that as a victory. Start with the small goals and celebrate them. We looked at the most common errors that were being made by the customer and determined that it was the application itself that was not clear in what was needed. Could it be that something as simple as revising the application could reduce the 55% rejection rate? Once the application underwent an extreme makeover, to our surprise, the error rate immediately dropped to 25%!

After speaking with the customer, we found that a few more revisions could be made to make the application more user friendly. To date, the rejection rate is now down to 5%. With the tools of the Lean Six Sigma methodology in hand, Ms. Neal took the initiative to improve her processes and won. She is a prime example of what Six Sigma defines as the “Engaged Employee.” These are employees that:

• know what the organizations vision is
• understand how his/her role fits into the bigger picture
• are willing to contribute discretionary effort for the benefit of the business

This is Ms. Neal. In January 2013, the BF&R and Lean Six Sigma team were recognized by the Board of Supervisors with a L.A. County Stars Award. Ms. Neal and her staff continue to look at opportunities for improvement within their section.

Continuing Success

Recently Mr. Logan held his annual “State of the Department” meeting, this is when he shares the top departmental accomplishments that have transpired over the past year. The theme was “Over the Top!” He challenged us all by stating “what you do well you can always do better.” When I heard this statement I thought of Darla Neal, she could have easily been complacent with the way operations were going in her section, but she took the initiative to make change for the better.

Mr. Logan also stated, “Adaptability is about new innovations and greater efficiencies – and it requires us to be open to new ideas and input.” Had Ms. Neal’s staff been closed minded, they would have missed out on an opportunity to make a difference in their operation. One good thing to remember is that anyone in the organization can answer the call to change; it doesn’t have to be the Lean Six Sigma team or upper management, all it takes is a desire to make things better.

Many successful Advanced Primary Care models have been implemented in community clinics or staff models where extended health care professionals, including nurses, health coaches or social workers, are part of the existing interdisciplinary team. The Advanced Primary Care model could provide added value to independent physicians practices by improving patient-experience through team-based care while increasing work flow efficiency.

How to implement a standard care model within small practices, in which the physician is in charge and has limited staffing resources, is to be determined. This article will relate the application of ‘Lean Thinking’ and change management strategies based on the “Rider and the Elephant” theory from the book Switch by Chip Heath and Dan Heath, which describes the implementation of the Advanced Primary Care model at four diverse provider offices that still function as independent small practices. This article will show how the combination of ‘Lean Thinking’ application and evidence-based change management approach from the book Switch can benefit small practices

Introduction

Background

Primary care practices are under tremendous pressure by the health care industry to do more with less, while demonstrating high quality outcomes. The passage of the Affordable Care Act1 ushered in the Triple Aim as coined by Dr. Don Berwick, the former Center for Medicare and Medicaid (CMS) Director and Founder/CEO of the Institute for Healthcare Improvement (IHI.) Dr. Berwick stated that improving the U.S. health care system requires simultaneous pursuit of three aims:

1. improving the experience of care
2. improving the health of populations
3. and reducing per capita costs of health care. (2)

The principles behind improving the patient’s experience of care is very consistent with what successful service industries have known for decades.

Creating a service experience that exceeds the customer’s expectation, is the key to quality and profitability. The United States will not achieve high-value health care unless improvement initiatives pursue a broader system of linked goals. The implication for the primary care offices is to build capacity to create a positive patient experience at each visit, while addressing the overall health of the populations or the panel of patients assigned to their practices. Last, but not the least, the primary care provider offices must be able to provide more value-added services with less financial resources. The good news is that the daunting dilemma faced by the US health care industry today have been solved by other industries such as Toyota’s experience, as described in the book Lean Thinking. (3) James Womack and Daniel Jones successfully translated the Toyota Production System, which combines operational excellence with value–based strategies to a Lean methodology, for adaptation to other industries.

This article will describe the experience of Best In Class (BIC) Physicians Group, deploying the Lean methodology in its adaption of the Advanced Primary Care model. This case study will emphasize the “change management” approach embedded in the BIC’s transformational journey to achieve the Triple Aim.

About the Best In Class (BIC) Physicians Group

The BIC Physicians Group consists of several traditional independent Board Certified physicians practicing in a culturally diverse Elsewhere county, USA. These physicians come together as part of an Independent Practice Association (IPA) in order to gain economies of scale by sharing administrative support services such as contracting, billing, practice management, and electronic health record systems support. Despite the fact that BIC is considered one single business entity, the physician offices continue to function separately with many variations in clinical and administrative processes.

Each BIC office has a loyal following of patients whom have developed trusted relationships over the years with the physicians and the office staff, however, other reputable medical groups have recently expanded their market into BIC’s territory in Elsewhere county. BIC began to experience a slow erosion of its membership base to the new groups as patients changed insurance coverage. In order for BIC to compete in the local market, it now needs to differentiate itself as the true “Best-In-Class” physicians group to gain back market share of patients with Medicare and Commercial health coverage. BIC physician management decided that in order to better compete, the offices must transform into Patient-Centered Medical Homes having standardized Advanced Primary Care practices, while retaining each physician’s unique style that attracted its current loyal patient base.

Primary Care Landscape Shifting to Patient-Centered Medical Home Model

The “Medical Home” is a concept coined in 1967 by the American Academy of Pediatrics and expanded over time as the “Patient-Centered Medical Home (4).” More recently, CMS approved the demonstration of the Advanced Primary Care (APC) model in the Federally Qualified Health Centers (FQHC.) The APC model relies on the use of physician or nurse practitioner lead collaborative teams of health professionals to provide patients with comprehensive and personalized primary care. According to CMS, medical care under APC requires a “shift from an acute care complaint-driven primary care paradigm,” which fragments health care delivery to one that is geared to maintain the patient’s overall health and anticipates when additional services or coordination needs to occur.” (5, 6)

Regardless of the “name du jour,” as the Affordable Care Act (ACA) unfolds, the key concepts of the “Medical Home” or “Advanced Primary Care” remain consistent describing a health care service delivery model in which the patient/consumer chooses a primary care setting (that may include specialty care services) as the basis for accessible, continuous, comprehensive, and integrated care. The interdisciplinary health care team provides evidence-based services from health management to disease prevention, matching an individual patient’s health care needs while coordinating with other services within the community. Instead of treating illness as the primary focus, the team proactively addresses the health care needs of its panel of patients, through proactive health risk screening and continuous improvement, driven by quality performance indicators. For the sake of consistency, this article will use the term “Advanced Primary Care” instead of the more familiar but slightly outdated “Medical Home.”

Many successful Advanced Primary Care models were implemented applying Lean techniques, adapting the Toyota Production System and the Six Sigma improvement approach in the community clinics or staff models. The Group Health (7) experience has been a well-cited experience and success story of the Advanced Primary Care model.Group Health clinics’ health care professionals (including physicians, registered nurses, health coaches, and social workers) are part of the interdisciplinary team in the clinics.

Since BIC Physicians Group is the largest Independent Practice Association in Elsewhere County, the Advanced Primary Care model could provide added value to the independent practicing physicians’ offices. Implementing such a paradigm shift in the traditional small practices, in which the physician functioned as the “boss” with limited staffing resources (consisting of mostly Medical Assistants), still has yet to be determined.

Since the literature has provided evidence of the efficacy of applying Lean techniques and Six Sigma methodologies, BIC physician managers chose to apply Lean methodology in the Advanced Primary Care model pilot in four very different provider offices. Additionally, they employed a Lean Six Sigma Master Black Belt consultant to train the providers and office staff to transform its operations to increase quality and efficiency by eliminating wasteful processes.

Current State

The Voice of the Customers

After the initial kick-off event that included key stakeholders, BIC physicians and physician assistants, the consultant conducted on-site staff training followed by a full-day Gemba Walk (8) at each office. The Gemba Walk process was designed to observe and document the current state from the patient’s perspective and experience. The consultant also interviewed the patients during their wait time to capture the Voice of the Customers (VOC). Table I summarizes the VOC from the four offices:

Table 1. BIC Voice of the Customers (below)

The Challenges

There are several challenges in applying the Lean approach to transform the BIC provider offices.

The first challenge was the time constraint of the offices. In the Toyota practice, the frontline workers are pulled off the production line to conduct Kaizen events over several days. But, implementing Kaizen–like events at provider offices can only be done during lunch time over a one to two hours maximum timeframe, to minimize interruption to the patient visits. The consultant had to be flexible and creative in condensing the Lean training into nuggets and deliver just-in-time actionable information. This condensed “crystalized” approach enabled the office staff to absorb the new concepts quickly and apply to tasks in real time, promoting active collaborative learning experience.

The second challenge was how to gain efficiency leveraging technology and standard processes among the providers from diverse generations and age ranging from baby boomer to generation X. For example, a standard process of documenting in the electronic health records during the patient visit and creating a complete patient plan by the end of the visit can be a monumental challenge for the physicians who never learned to type and are not comfortable using the computer during the face-to-face patient visit.

The third challenge was how to gain consensus among the physicians to one “best practice” when each physician views his/her office as the very best amongst peers.

Opportunity for Change

The Switch

The key concept of the book Switch by the Chip Health and Dan Heath is “how to change things when change is hard.” (9) Switch successfully translated evidence-based change management theories into practical application, taking into consideration that our minds are ruled by two different systems – the rational mind, represented by the “rider,” and the emotional mind, represented by the “elephant”– that compete for control. (9)

The consultant applied these principles as part of the key change management strategies in the Lean transformation of the four BIC practices.

How We Direct the Rider – The Logical Mind

Find the Bright Spot

Many of us aspired to be a doctor in high school, but few of us make it into medicine. Typically, the best and brightest students get accepted into medical school. It takes determination, dedication, and hard work to complete the medical training and residency to become a physician. The BIC physicians are also Board Certified, running their own small practices as successful entrepreneurs.

There is a certain pride and passion about practicing medicine independently. Therefore the consultant’s first step was to harvest the bright spots and showcase what is working well in these offices that can be replicated. For example, one doctor consistently delighted the patients by remembering special information about the each patient, such as who referred them, special life events, and interests.

The physicians simply utilized the “sticky notes” feature of the electronic health record to document personalized information about the patient and pulled them up during each patient visit. All the medical assistants were trained to utilize the “sticky notes” to deliver personalized services. One office minimized the perception of waiting time by moving the patient into an exam room as soon as one is available and prepared the patient for the physician visit. The constant personal contacts and continuous flow of services minimize the patients’ perception of a long waiting time for their doctor. Another office sought to improve the experience of the patients’ parent by accommodating a group visit of several siblings at one time for well-child care, primary to school starting. Many of these bright spots can be incorporated into the Advanced Primary Care model.

Script the Critical Moves

There are many change elements required to be certified as a Patient-Centered Medical Home by the National Committee of Quality Assurance (NCQA.) To tackle all the requirements at once can be daunting. The four pilot sites were given a listing of Advanced Primary Care change elements (termed a ‘menu’) to consider at the start of the process.

After conducting the Gemba Walk, harvesting the bright spots, and presenting the findings to each individual office, the consultant then convened a Think Tank of the physician champions, physician assistants, medical assistants, and office managers to review the current state and reach a consensus on standard processes and works. Then, the Think Tank participants presented the proposed standard activities categorized by before visit, during the visit, and after the visit to respective office teams for additional feedbacks.

The collective document is converted into a roadmap for the BIC office managers to follow- through in collaboration with each office team. For example, one of the scripted moves on the roadmap was how to conduct a five-minute daily huddle at the office. A standard checklist, including who should be present at the huddle, and what should be discussed was to be created and implemented at each office.

Point to the Destination

The destination of this initiative was clearly articulated from the start at the kick-off meeting by one of the most respected physician leader. He painted a vision that BIC is going to be the best-in-class premier medical group in the local market offering Advanced Primary Care model leveraging electronic health records in each offices with efficient standard processes and standard work. BIC aims to be the provider offices of choice with Five Star rating and be in the top quartile in quality performance among the IPAs in the national market.

How We Motivate the Elephant- The Emotional Mind

Finding the Feeling

People, who choose the health care career, typically are mission-driven and compassionate individuals who find purpose in their professional work. As health care becomes a commodity traded on Wall Street, and the payers start to drive how health care service is delivered instead of by the physicians, many health care professionals including the physicians become discourage or disenfranchised. To help the BIC providers to find the feeling, they were asked to imagine the ideal health care visit for their Grandmother.

How should we transform BIG’s office, so they would choose BIC for their loved one. The feeling amplifies the health care professional’s calling and responsibility to shape the future of health care for people we care about. The BIC providers realized that they are part of the larger health care reform effort with the responsibility to fix the unsustainable health care system for our future generations. The Advanced Primary Care prototype as developed through BIC’s transformation can be replicated to help other small practices.

Shrink the Change

In order to gain the non-pilot sites buy-in, two of the physician champions agreed to “sell” the BIC Advanced Primary Care model to the other BIC providers who were not part of the pilot. Instead of presenting all the details of the visits standard processes, the physician champions will propose two to three standard processes from each phase of the visits, including care coordination activities between visits to be implemented in all BIC offices during the next twelve months. The other providers will be given the opportunity to provide input and help shape the scope of change within realistic constraints of time and resources to demonstrate return on investment.

Grow Your People

The BIC providers and staff are expected to be the best among the other IPAs. In addition to be identified as the best-in-class, the BIC pilot sites are often selected as innovation sites to test other new ideas. The pilot sites are empowered to identify improvement opportunities based on the Gemba Walk findings and Value Stream Map analysis. They were encouraged to apply rapid cycle improvement methodology and small test of change in their work areas. These small tests of change offered a safe opportunity to learn from failures and to recalibrate the next change effort using objective data. Failures were considered a necessary step of the learning process. Participating in the Think Tank shoulder-to-shoulder with the physicians gave the medical assistants the confidence to share their better ideas. The interdisciplinary Think Tank environment seeded a collaborative culture among the team and paved the ground for continuous quality improvement as BIC implement the Advanced Primary Care model as the best-in-class.

How We Shape the Path

Tweak the Environment

BIC offices are traditional doctor’s offices with a waiting room, front office, back office, and exam rooms. Most of the offices have limited space. During the Gemba Walk, wasted motion muda or waste was observed in several offices. For example, the printer is often placed far away, such as in the medical records room down the hall. The front office staff has to leave the front desk and walk down the hall to retrieve documents for the patient. A quick-win of tweaking of the environment was to move the printer at an arm’s reach distance of the front office staff. Patients often sit in the waiting room for a long duration waiting to see their doctor. One idea of tweaking the environment is to eliminate the waiting room completely, which was actually done successfully in other medical groups.

Build Habits

In order to build new habits and institute standards that reflect best-in-class primary care services, two tactics will be implemented to build new habits across the board. The first tactic is the humble check list. For example, the team will be trained to use a checklist to cover important topics during the daily huddle; a checklist of standard supplies and equipment to stock the exam room; and a checklist of in-office lab to be done for various types of patient visits. The second tactic is a standard script for all staff and patient communications to ensure a consistent patient-centered brand messaging. For example, a standard phone greeting script, an outreach script for preventive services, and a script for post hospital discharge calls.

Rally the Herd

The BIC Advanced Primary Care Lean initiative was rolled-out as the organization approaching its annual strategic planning cycle. The provider champions were invited to participate in the strategic planning process and define measures of success reflecting best- in-class performance of the BIC offices. These performance measures included results from elements of the Advanced Primary Care Lean initiative. The plan is to develop a transparent performance dashboard for each BIC office to show individual and team performance on a monthly basis. The dashboard will provide transparency among the peers and rally the herd to perform as BIC Physician Group name implies – the Best-In-Class!

Strategy to Keep the Switch Going

Under the shifting landscape of health care reform, transforming the small IPA provider offices in lightning speed to become best-in-class is no small feat. In order to keep the switch going at the BIC Physicians Group, additional wrap around support is clearly needed. The IPA organization of BIC plans to re-direct several corporate clinical professional staff to provide virtual and on-site support. For example, one case manager will utilize predictive modeling tools to help BIC providers identify and stratify patients by risk levels. The nurse case manager will also bring other discipline such as a social worker and clinical pharmacist to the patient care conference based on the patient’s care needs. The IPA medical director will help facilitate the weekly patient care conference for patients with complex high risk factors. The office managers will create a training program to re-train office staff on the standardized process and work across all BIC offices. The consultant will continue to serve as a sensei (teacher and coach) for BIC as it continues on this never-ending journey of seeking perfection.

Conclusion

Recognizing change is a dynamic process involving the rational mind and the emotional mind. It can be very helpful in implementing change in the health care sector. Change in the primary care providers’ offices involves motivating the highly educated physicians as well as the frontline medical assistants with minimal technical training. While Lean Thinking and sophisticated Six Sigma methodology are useful to implement improvement, effective change management can be expedited with the help of an objective facilitator or consultant who understand the intricacies of creating a change strategy that resonate with both the rider and the elephant; when the riders and the elephants move in unison, sustainable change will happen.

References:

1. Patient Protection and Affordable Care Act, Health Related Portion of the Health Care and Education Reconciliation Act of 2010, Public Law 111-148 (2010). Retrieved from http://housedocs.house.gov/energycommerce/ppacacon.pdf
2. Berwick, D.M., Nolan, T.W., & Washington, J. (2008) The Triple Aim: Care. Health, And Cost. Health Affair, 27(3), 759-769
   doi: 10.1377/hlthaff.27.3.759 Health Aff May 2008 vol. 27 no. 3 759-769
3. Womack, J.P., & Jones, D.T. (2003) Lean Thinking. New York, United States: Free Press.
4. American Academy of Pediatrics. Retrieved fromhttp://www.medicalhomeinfo.org/publications/medical%20home.html
5. Federally Qualified Health Center Advanced Primary Care Practice Demonstration Demonstration Design. Retrieved from http://www.cms.gov/Medicare/Demonstration- Projects/DemoProjectsEvalRpts/downloads/FQHC_DemoDescription.pdf
6. Kurzweil, V. (2011, November 220. Re: CMS Demonstration to Test Efficacy of Advanced Primary Care Model, [RegBlog message]. Retrieved from https://www.law.upenn.edu/blogs/regblog/2011/11/cms-demonstration-to-test-efficacy-of- advanced-primary-care-model.html
7. Reid, R.J., Fishman, A., Yu, O., Ross, T. R., Tufano, J. T., Soman, M. P., Larson, E. B. Patient centered medical demonstration: a prospective, quasi-experimental, before and after evaluation. The American Journal of Managed Care, 2009; 15(9): 71-87
8. Gemba Walk Definition. Retrieved from http://en.wikipedia.org/wiki/Gemba
9. Heath, C., & Heath, D. (2010). Switch. How to Change Things When Change is Hard. New York,United States: Broadway Books.

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Embarking on a Lean Six Sigma Program can be an expensive proposition and the return on your investment can take time to materialize. Leadership is often left with difficult decisions around who to send to improvement workshops. Training all of your employees to become Green Belts or Black Belts would be like bringing the Olympic 400 Relay team to your neighbors pool party. Your neighbor would be a little overwhelmed and the swim team might not know what do to do with themselves.

Too Fast Too Spurious

Organizations who rush to train as many project leaders as possible in as short a time as possible face a host of repercussions. Training an individual employee to become a project team leader can cost upwards of $3,000 per employee per training week. Another issue is organizations are generally not in a position to launch the number of necessary projects to keep all the new team leaders active. Without immediately practicing their newfound Lean Six Sigma expertise, workshop participants fall prey to the “use it or lose it” syndrome. Many a training dollar has been spent in vain this way.

When You Care Enough to Train the Very Best

But the flipside of over-training can be equally detrimental. Faced with the decision of where to invest precious training dollars, some leaders opt to focus on a small, select group of project leaders to lead the charge. This saves money in the short term but without solid awareness of their role in process improvement, the organization risks losing the support and participation from management and front line staff. When the workforce is divided between the well versed and the uninformed then buy-in suffers. Team leaders have to spend more time selling their solutions resulting in a more burdensome effort to bring projects to completion. This increases the time to achieve project gains, and time is a terrible thing to waste.

Because They’re Worth It

When you ensure that all key members of the organization have a solid understanding of why Lean Six Sigma is good for them and the business, you prepare them to provide project teams with the information, data, process knowledge and approval they need for faster project completion. Bringing large groups together for a FastPitch shared process improvement experience builds that essential organizational awareness necessary to build a workforce that’s not just informed but ready to partner in reaching improvement goals. An engaged workforce can dramatically speed the time to organizational benefits.

Launch It Your Way

FastPitch enables organizations to not only give large groups of employees a thorough understanding of Lean Six Sigma but it also generates genuine excitement and engagement for less than one tenth the cost of a week of Green Belt Training. A fully facilitated FastPitch session including the kit and workbooks can cost from $200 to $350 per employee. You can bring costs even lower while increasing in-house expertise with our Train the Trainer program. Contact us now for details on how to bring FastPitch into your organization.

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A key objective of every project is to deliver results in an agreed upon time period with an agreed upon set of resources. Three important factors that are critical to accomplishing this are:

1. The project is well defined
2. The project is scoped properly
3. The project is resourced adequately

Beginning Your Lean Six Sigma Project

At this early stage of the project, the involvement of the project sponsor is critical and the sponsor/champion works with the project lead and project team in defining and resourcing the project. Typically, the sponsor is the manager/executive accountable for the process and resources that the project is addressing.

1) The Lean Six Sigma Project Is Well Defined

Articulating what the project is addressing is critically important. The project definition is captured in a project charter also known as an A3 in the Lean world. The process wherein the project resides should be named. If the project is addressing an issue within the Product Development process or a sub-process within the Product Development process, it should be identified. Also to be addressed is the specific issue the project is addressing is important. For example, a project within the Product Development process may be addressing a cycle time issue. This specific issue is typically the problem definition of the project. In a textile production example, a project may be addressing the defect rate of greige (unfinished) fabric on a particular loom, plant or greige type.  The process is the Production of Greige Goods and the problem is the defect rate. The project is further clarified with data quantifying the problem. How long is the cycle time compared to standard or what is its impact? How many are late? What is the consequence such as penalties or missed deadlines? In the greige goods example, what is the defect rate and what is that cost and/or consequence?

2) The Lean Six Sigma Project Is Scoped Properly

It is important to have boundaries and limits to what the project will and will not include. Scope issues correlate to project duration. Well scoped projects tend to finish on time. Projects scoped to issues directly related to the identified process are projects that can be managed to shorter time frames. A project duration of two-five months is an objective to work toward.

In defining the project, a process is identified. Process boundaries are one aspect of project scope. Processes upstream or downstream of the named process should be out of scope preliminarily as the project get underway. Additionally, there are other scoping issues that need to be considered such as systems architecture and IT issues. The project should examine input and process issues are inherent within the named process and problem identified. So a project may initially include vendor issues but exclude the vendor selection/qualification process.

3) The Lean Six Sigma Project Is Resourced Adequately

The resources for the project should be related to the process and problem identified and the defined scope. Resources typically include people and budget and may include other assets such as equipment etc. The staffing of the project should include personnel from the process identified and important stakeholders who influence the process such as a supplier to the process. This “core” team should be 4-7 persons. Small core teams are more effective than larger, unwieldy teams. Please note that a project with a small core team may still involve 10-20 other people from the organization as the core team goes through the process of measuring, analyzing and improving the process. These additional people may provide needed data or assistance with systems or financial assessments etc.

This upfront project definition work will greatly facilitate the project in meeting its objectives in a timely manner.

The “To Be” or Future State of the process is a critical component of the Lean methodology and the Value Stream mapping exercise.  It is a powerful exercise that strokes the imagination and helps break free from the current inhibitors of the current state which are contributing to any one of the seven wastes.

Previously, we’ve covered How To Visualize a Process With a Value Stream Map which explained how to map a process in it’s original, or current state before process improvement or Lean Six Sigma is applied to it.

The exercise of mapping the current state, capturing the relevant data in the data boxes and chronicling the 8 Wastes have sparked ideas for the future state in most instances.

Thus, the future state begins with the imagining of the process without the non-value added activities and the elimination of the seven wastes including those in value-added steps.  In an earlier example of a ‘Current State’ value stream map (VSM), we documented the replenishment process for a food manufacturer.  The total cycle time was about 55 hours which made the replenishment process from receipt of the planned load to delivery almost 3 days.  From the current state analysis, the team identified a number of improvements desired in the process.  Working with the IT support group, selected transportation vendors and warehouse staff, the team realized their goal of plan and pick-up within 24 hours was achievable and that improved routing guides in lane management and working with preferred carriers would reduce transit times.

The team created the ‘Future State’ or “To Be” value stream map. The non-value added times were reduced in every step.  The improvements included:

• improved routing guides
• dedicated lanes to vendors
• mandatory electronic tie-in of all carriers for improved auto tendering
• mandatory EDI communication with smart devices
• system interfaces in hourly batching

The improved auto-tendering of loads, reliance on preferred carriers  and compliance with routing guides reduced manual interventions and handling reducing FTE staff in the upfront processes.  This actually freed up staff to transfer to the vendor management group which was in need of staff.  Headcount in the planning process on non-value added staff could transfer to value added activities to another group within Transportation.

Overall improvements as envisioned by the Future State included a nearly 50% reduction in cycle time from 55 hours to 29 hours, 4 FTE (full-time employee) reduction in the tender and scheduling process, a yield of at least 95% compared to 63%, and an improved process efficiency from 5% to almost 13%.

The determination of the “how-to” make the improvements happen were scheduled in Kaizen events. Interestingly, the internal IT support group was able to implement improved batch cycling between applications quickly whereas the electronic linkage with the carrier groups would take a longer time due to capital investments incumbent on the external vendor.

Actual achievement of the ‘Future State’ may be captured in steps or a series of Kaizen events but the ‘Future State’ is the driving force.  Be bold with the ‘Future State’.  Start with what the process looks like by attacking and trying to eliminate the 8 Wastes.

Lean County, USA is where everything runs just fine.  Actually, things are more than just fine; they are fast, friendly, and efficient. In Lean County, you can order your birth certificate online and get it delivered to you the next day.  And if you’re in need of food stamps, you can rest assured that you will have everything you’re entitled to without waiting in line or creating a mound of paperwork.

Background

In Lean County, you could even purchase a home and go through the shortest escrow you ever heard of.  And if you want to remodel that home, well you can get a permit when you need it so that you don’t ever have to worry about delaying your plans.  Crime in Lean County is pretty low, but if someone does something wrong, the public can feel safe knowing that convicts are paying their debt to society.

Although this is just an example of utopian government, this should be the ideal that public servants strive for.  Perfection is rarely expected, but trying for it always should be.

Perceptions of County Government

The prevailing opinion of government these days is that it is too slow and wasteful to be effective.  And the larger the government, the worse the opinions seem to be.  Federal agencies are regularly in the news for excessive spending and ineffective public service; however, smaller County government is most often criticized when people interact with it personally.

Local government entities, such as Los Angeles County, provide the public with critical services that affect everything from property taxes to food stamps, from voting in an election to locking away dangerous criminals.  When a person has a bad experience with local government, it usually means that it may have a negative impact on their life in some way, which means that excellent service should be of utmost importance.  Unfortunately, there are many bad experiences out there and, subsequently, many poor opinions of public agencies.  Given that local government has such a great impact on lives, there are a few questions that need to be asked:

1. Why is it important to know what the public perception of County government is?
2. What can the County do to improve it?
3. How will changed perceptions change everything?

1.  Why is it important to know what the public perception of County government is?

In general, the public (i.e. residents, constituents, PEOPLE) are customers of the County.  Ask any successful CEO if public image is important to the company and the response should be absolutely, yes.  Of course, private companies care about their image with customers because they are interested in gaining revenue and profit, but public agencies should care as well however for different reasons.

Public agencies, especially local government, should care about customer opinions because they are usually customers themselves (and usually so are their families).  Employees at a private company, such as Apple, probably strive to create the best products and services because they own Apple products and see themselves as the end user.  In the public sector, many County employees are their own customers too, so why wouldn’t they want to create the best experience for themselves and the people they know?

Public agencies should care because it’s also the first step in improving services.  If a department never knows what is important to its customers and how it is performing in that area, it will probably spend much effort trying to improve something that was never important to customers anyway.  And that thing that was important to customers may never get the attention it needs.  In order to make meaningful improvements, it is important to know what matters to the people you are improving for.

Public agencies should care about their image simply because there should be pride in public service.  County government has a heavy responsibility to provide services that are essential to making the world go round.  Bureaucracy and hierarchy may trivialize the importance of some jobs and services, but a valuable reminder for government is that what they do is important to many people.

2.  What can the County do to improve it?

Improving public perception of an organization is never easy because it relies on changing the attitudes of many different people.  Of course, it is challenging to make all the people happy, all the time, so that should not be the goal of County government – not right away.  These are a few things that County government can do right now to improve the public image:

Public servants need to listen to customers when they complain.  If surveys and complaint cards are ignored, then they serve no purpose other than to give the mere appearance that a department cares.  After a while, that appearance wears down once people realize that nothing is being done to address their complaints.

Make positive change happen by creating a place for it that won’t be bogged down by red tape. When barriers to change are removed, process improvement is able to flow faster and everyone, especially the customer, reaps the benefits.  This can lead to a culture of continuous improvement where processes are constantly evaluated and incremental improvements are made when needed.  When this type of culture is embedded in the County, the public will see local government in a whole new light.

Be the customer in line waiting for County services.  As stated earlier, many County employees are customers themselves, but they may not use the services very often.  Many services offered by government are needed only occasionally or periodically; for instance, copies of birth certificates or property tax assessments.  It would be beneficial for the County to test their services on a regular basis and compare the performance to the public’s expectations.

3.   How will changed perceptions change everything else?

In times of financial crises, many people begin to support broad budget cuts to what they believe to be wastes of tax payer money.  Typically, the services considered to be wasteful of tax money are those that benefit the well-being of those most in need (e.g. senior citizens, low income families).

If the County government can run more efficiently and be held accountable to the public, there should not be such strong support for these types of dramatic cuts.  Drastic budget cuts only cause further economic damage and create more ineffective services.

Once the public stops seeing County government as slow and inefficient, public trust will be put back into the system.  This can only happen once the County proves that it can be effective and efficient when carrying out its services.  In the end, improved services should achieve the County goal of enriching the lives of Los Angeles County residents.

The Registrar-Recorder/County Clerk

The Registrar of Voters and County Recorder were merged in 1968 by the Board of Supervisors and further merged with the County Clerk in 1991.  Although these disparate functions came together only 21 years ago, the individual processes have been running since the 1800’s.

The Registrar-Recorder/County Clerk (RR/CC) is responsible for one of the largest document repositories in the country.  In addition, the RR/CC must maintain voter files and conduct elections for Los Angeles County, which currently has over 4.1 million registered voters and up to nearly 5,000 polling locations.  The services performed by the department are critical to the local business owners who register their business names and the homeowners who record property documents.  It is also important to every person who was ever born, married, or died in Los Angeles County that RR/CC maintains accurate and accessible copies of these certificates for the public.

Processes Greater Than RR/CC

Something that is often misjudged when studying processes critical to customers is the scope of the process, meaning the beginning and end of a process.  Finding out where these two points are can be difficult and are sometimes overtly avoided because people do not want to take on more than they can handle.

Within a department, such as the RR/CC, there are internal processes that have their own cycle time and value streams; however, entire departments are often just a piece of an even greater puzzle that people go through to accomplish critical tasks.

For instance, when refinancing a home, a resident must deal not only with their mortgage company, but also with the Tax Assessor’s Office and the RR/CC (two distinct county departments).  For someone who needs to secure a lower rate on their mortgage to make lower monthly payments, it is imperative that these three entities work for the customer.  And lower rates may only be guaranteed for a short time, so time may be critical.  If all of these entities believe they are performing just fine with a turnaround time of 7-14 business days that may mean a 21-42 day process for the resident.  If anything in this process were to go wrong, it could cause an even greater delay that may have a huge impact on the daily life of residents.

Although it is not always necessary (and normally impossible) to bring outside entities into scope when thinking about improving departmental processes it can be beneficial for the customer to consider those external forces.  No department is an island; therefore, it must consider its relationship to the entire process.  In order to truly improve government services, at any level, it is crucial to work collaboratively with many agencies because that is what the customer goes through.  And in order to work with multiple agencies, it is vital to create a core team of business process improvement experts in all aspects of government.

Lean Six Sigma works for the RR/CC

The RR/CC began using Lean Six Sigma (LSS) as a process improvement method in May 2011.  Its foundation was laid out nearly one year prior when a new unit was formed, Quality Assurance.  This unit was to be the agent of change that would improve departmental processes and create a culture of continuous improvement – and it did.

Lean Six Sigma was selected as the method of choice because of its success in the elections field of King County, Washington.  By June 2011, all six members of the Quality Assurance team were trained as Green Belts in Lean Six Sigma, and by October of that same year all members were trained Black Belts.  Three of these Black Belts were later selected to undergo Master Black Belt training so that the department could sustain Lean Six Sigma mentorship internally.

A Different Way of Thinking

The Lean Six Sigma methodology works for the RR/CC despite the different approach to problem solving that many public agencies do not practice.  Lean Six Sigma promotes problem solving through a facilitation of exercises with subject matter experts, which is the opposite of standard practice.

It used to be that when something needed to be improved, managers would get together and talk about the problems and possible solutions in a closed door meeting.  Sometimes they would invite a subject matter or two to chime in, but they were never considered the authority of their operation.  When using Lean Six Sigma the RR/CC relies primarily on subject matter experts to formulate solutions, and most importantly, without the presence of upper management that may impede creative thinking.  It’s understandable that lower level employees may feel inadequate or uncomfortable when speaking in front of their executives; therefore, Lean Six Sigma creates a different venue to allow people to think freely.  Of course, managers are informed once solutions are proposed, and are involved if any solutions require additional resources or authorities.  But most often, solutions do not require much money, advanced technology, or additional staff.

It also promotes the idea of continuous improvement and project oversight that is not always found in process improvement discussions.  Those trained in Lean Six Sigma know that a critical part of improving something is maintaining control over the improvement.  Although the LSS team (Quality Assurance unit) facilitates the improvements at RR/CC, the process owners become the subject matter experts themselves.  This also leads the way into knowledge transfer where the subject matter experts become so familiar with LSS from the projects that they begin using the principles to make improvements elsewhere and continuously improve.

The Current State of Lean Six Sigma at RR/CC

The Successes

Improvement projects were done concurrently with the training and the RR/CC began to see results immediately.  In the first project, the turnaround time for requesting copies of birth certificates by mail dropped dramatically from nearly three weeks to one day.  Another project saved several hours per day for cashiers and their supervisors when changing shifts for lunch breaks.  One project in the Vote By Mail area focused on reducing unnecessary handoffs and simplifying the process, which improved the cycle time for certain sub-processes.  And a project that studied provisional ballot processing found that fewer temporary employees were needed; which allowed those employees to be placed in other areas that required more staff.

The success of the Lean Six Sigma program at RR/CC may come to mean a great deal to Los Angeles County as a whole.  The RR/CC was the first department to take the initiative of creating a process improvement unit trained in Lean Six Sigma.  In many ways, the department is the model for other County departments that want to create positive and sustainable change by continuously examining their processes and focusing on improving services in a systematic way.

Successful results from the Lean Six Sigma projects came in part from the training, but are more so attributed to the guidance provided by a Master Black Belt (MBB) consultant.  The results would not have been so drastic without the experienced facilitator to lead the way and instill confidence in the team.  Although the Lean Six Sigma team was trained in Green Belt, the MBB helped the team choose the right tools for the projects and gave them hands on experience in facilitating their own improvement workshops.  This deeply involved mentoring is what allowed the team to eventually sustain the program once the training wheels came off.

Another factor that was as important as any other was the support from the top level management.  The Department Head (similar to President of a company) was the one who initiated the program and set the stage for it to flourish when his team created the Quality Assurance Unit, which would become the home for Six Sigma.  With his strong support, his team sought the funding to purchase training and consulting hours.  Without support from the top, not only would the program be more difficult to implement, it may not have ever seen the light of day.

The Challenges

Every fairytale has its share of dragons and hurdles to overcome, and the tale of how the RR/CC became empowered with the dagger of Lean Six Sigma is no exception.

Getting (Some) Managers On Board

Sure, the Lean Six Sigma team had support from the very top managers in the department, but some other managers had trouble accepting the new direction they were told to go in.  Most of these managers held their reservations close to the chest and were kind enough to go along with the process.  They would eventually become advocates of the process once the results spoke for themselves.  Others, however, made their resistance obvious from the beginning.

One manager wanted to participate in a Gemba walk, which is basically an in-depth walk through of a process from beginning to end.  This exercise is normally done with the people actually doing work, or Subject Matter Experts (SMEs).  Managers are not usually involved in this walk because of the natural inhibition that most employees may feel when their managers are asking them to describe how it is they do their work.  The purpose of the Gemba is to gain profound knowledge of the real process, and that can be difficult when employees do not feel at liberty to speak honestly about the process.  Despite the appeals of the experienced Master Black Belt, the manager insisted to be present at the Gemba walk.

The results of that walk were fruitful in some ways, but the overall tone and experience for those involved was unpleasant.  It was obvious that many of the manager’s employees were intimidated to speak about their jobs comfortably.  No matter how “down to Earth” the manager believes he/she is, employees will feel that anxiety if their presence is there.  For some employees, it is difficult enough to speak to a group of people coming into their work space and asking a litany of questions.  And for some, this may be the first time anyone has asked them to speak candidly about their job and process.  Having a high level manager attend the Gemba does not help the process improvement; it only helps the manager feel more in control of it.

Losing Team Members

When you do well, you are rewarded for it.  When you do too well, you are punished for it.  That second statement may be an exaggeration, but it definitely describes what seemed to happen after nearly a year of successful process improvement.

The Lean Six Sigma team successfully implemented changes all over the department and received recognition at all levels of the County.  It was inevitable that someone from the Lean Six Sigma team would be called upon to serve in another capacity.  The leader of the Quality Assurance team was given the opportunity to manage a division within the Elections Services Bureau of the RR/CC.  Promotional opportunity is a great motivator for people to work harder, but in this case it took away the leader of a growing unit.

Now, the challenge is finding a suitable replacement.  The entire team is trained at the Black Belt level or higher, so anything less in a leader would not be fitting.  This is, in part, an issue of trust.  Trust is an invaluable quality to have in a team like this, so there needs to be trust that a new leader would foster the vision already had by the whole team.  Also, the new leader will need to already have knowledge of implementing Lean Six Sigma because the program is already moving full speed.  There will be no time for catching up and the team will need to trust its leader that it can accomplish all of its goals.  For these reasons, it is a challenge to find a suitable replacement without looking to the team members themselves.  Probably, the best candidate will come from the team.

Too Many Hats

Although the Quality Assurance team was initially created so that process improvement could have a home at the RR/CC, naturally there are other tasks and responsibilities that have been piled on over time.  The unit is now called, Quality Assurance and Records Management, which means that the team has added a couple of more people to help with the additional tasks.  The team is also responsible for responding to Public Records Act requests, but no additional people were needed to handle this task.  In all, there are three very different functions of the group and it can be challenging to devote proper attention to improvement projects because of the other duties.

Election Schedules

The department conducts elections throughout the year and when they occur it is all hands on deck.  It can be challenging to improve election operations when the people are too busy doing the work to devote any time to improving it.  The election schedule can also get in the way when trying to improve non-election areas because sometimes the election requires additional staffing from all areas of the department.  Elections put a strain on the department; however, the challenge in it of itself is evidence that work needs to be done to improve the processes.

How it is being embedded in the culture

The culture of continuous improvement began with the Department Head who promoted the theme of the “Game Changer” at an annual address to employees.  Wristbands bearing the theme name were given to every employee and worn throughout the year by most people.  The idea that we were all “game changers” and that we were going to embrace a new way of thinking/doing business was talked about at every opportunity by the Department Head.  It almost became a reason to take on challenging projects – we’re doing it because we’re game changers.

Those that played a role in assisting the Lean Six Sigma team in improving their operations were recognized frequently through different award programs.  One process improvement team was even recognized for their efforts by the Los Angeles County Board of Supervisors.

Another way the Lean Six Sigma culture is being embedded in the department is in the collaboration and relationship between the Lean Six Sigma team and operational units.  The Lean Six Sigma team has shown others that it listens to the needs of the department and is able to respond with action.  The team has worked with various operations on ad hoc projects that have given operational staff ownership of the solutions and their processes in general.  These positive experiences with the LSS team spread by word of mouth throughout the building and are paving the way for success in the future.

How the people will shape its future

Despite the challenges, the future of the Lean Six Sigma program at RR/CC will depend on the people who are key players right now.  The Lean Six Sigma team has one fewer person dedicated to process improvement, so the rest of the team will need to: 1) continue to work toward the same high standards; and 2) stay in the Lean Six Sigma unit.  The goals of the program are too lofty to be placed on a shrinking team.  It will be crucial for the Black Belts and Master Black Belts to keep with the team and continue to drive it down the road of success.

Executive management has an opportunity to take an already successful program and take it beyond its boundaries.  The team can train other employees and even employees of other departments throughout the County.  It could lend its services to other departments who struggle with projects of their own or help others build a similar program.

In order for the future to remain bright for the Lean Six Sigma program, there needs to be structure within the program to withstand attrition and the variety of duties and goals of the team.

Opportunities to Enhance the Program

A training academy

The Lean Six Sigma program would improve its sustainability and overall success by developing a training program.  A preliminary training schedule has already been developed and will be implemented later this year.  However, expectations of trainees will need to be looked at more closely and must be accounted for in some way.  Ventura County has a longstanding training academy that could serve as a model for the RR/CC when administering the training.

The training should outline the requirements and expectations of trainees, which should be the completion of projects and delivery of results.  As done in Ventura County, there should be a council that meets with the certified practitioners to ensure that they continue to produce a minimum amount of projects per year.  Those that do not deliver projects would have their certifications revoked.

Search for high impact/low effort projects

A high impact project/low effort project is one that can basically get you the best bang for your buck.  The Lean Six Sigma team has already done a few of these and the results are not just in the process, but they are in the relationships between the team and the operations.  These relatively quick projects help to promote the program without investing too much time in them.  This is an effective way of getting out to those areas that want the help of Lean Six Sigma.  Once the Lean Six Sigma team gets a taste of what is happening in an area, a more thorough and investigative effort can take place.

Be reward driven

There should be no doubt that rewards are good drivers of hard work and success, therefore rewards should be created to grow the Lean Six Sigma program.  There could be rewards for Lean Six Sigma team members, operational staff, and new Lean Six Sigma trainees.  Rewards are often in the form of recognition, but the usual forum of recognition in the department has become inundated that it may not hold much meaning.

With Lean Six Sigma team members, categories of awards can be created so that team members strive to achieve in all categories.  These can be formulated to effectively grade the completed projects by awarding the project lead and support with a color coded ribbon that indicates the level of accomplishment.  A black ribbon could be awarded to indicate the highest level of accomplishment while a green ribbon could represent a modest improvement in a process.  There could even be yearly or periodic awards for “Most Improved Process”, “Greatest Cycle Time Reduction”, or “Most Profitable Project”.  These would be tangible and meaningful awards that could motivate people to push further.

In order to motivate operational employees when participating in process improvement, awards similar to the ones above could be given and kept in their personnel file.  By doing this, employees would be able to reference their accomplishments when trying to attain a promotion.  Perhaps the most successful teams could even receive the uniform of Lean Six Sigma team members.  Currently, the LSS team dons a polo shirt with its own logo that indicates the level of training the member has accomplished.  Specially made t-shirts could be created for these people to make them feel more part of the process improvement team.  It could become known to everyone in the department that in order to receive the “jersey”, you must work hard at improving your process.  It would be similar to having a letterman jacket in high school.

Once the training academy begins certifying employees in Lean Six Sigma there will be a need to encourage those new trainees to go out and make positive changes in their areas.  Oversight will always be conducted by the Lean Six Sigma Master Black Belts, so the awards for them could be based on projects completed after their training.  The training academy should require a number of projects to be done, but the reward aspect would ensure that they are of high quality by creating a competitive environment.

Assist other public agencies

There exists an opportunity to make an even greater impact on the services of Los Angeles County.  So far, the focus has been on improving the services offered by RR/CC, which can affect those who wish to vote, purchase property, start a business, and obtain records of identity.  But if we are to be a Lean County and truly change the perception of government and public service, the processes of every County department will need to be improved in some way.  The greatest achievement will come from improving all County services and improving the lives that depend on these services.

The RR/CC should lead the way and assist other County departments in implementing Lean Principles and the Six Sigma methodology.  With the assistance of a certified Lean Six Sigma consultant, Tracy O’Rourke of Catalyst, the case for improved services is self-evident, which is why the County, as a whole, should embrace it.  The RR/CC, having deep knowledge of Lean Six Sigma, bears a responsibility of spreading the way of continuous improvement to every corner of the County.

Tracy O’Rourke explains what Lean Six Sigma is, why businesses use it, and why it should matter to you as an individual.

The following is a transcript of this video:

I do a lot of travelling and the biggest question I get is “what is Six Sigma?” So I’m going to spend a little bit of time talking about:

• What Lean Six Sigma is
• Why companies are using it
• Why it’s important for companies to have an initiative
• And why you should care about that, what does it do for you as an individual

So obviously it’s important to know what companies want if you want to get a job, but it’s also important to know what it really does for you as well. So I’ve put all that in there and I’m going to try to cover it in 15 minutes.

So here’s just a little bit about me and some companies I’ve helped. I started in this industry at GE. I was actually in sales and they asked me to become a Black Belt because they wanted me to talk to GE customers, and they tried a few engineers in that role, it didn’t really work out. So they thought it might be easier to train me how to talk about statistics rather than try to teach a statistician how to talk to customers – that’s not what I said, that’s what they said. It worked out pretty well.

What is Lean Six Sigma?

I’m going to talk a bit about Lean; this is at a really high level. It is under the process improvement umbrella. So what that means is that you’re trying to improve processes, and when I talk about processes, I’m talking about processes in all kinds of processes in all types of Industries. You can see that Jack had mentioned that I’ve been helping Callaway Golf, DC Shoes, financial services, the government – you can apply this anywhere. If you don’t know the root cause of the problem, you can apply Six Sigma and Lean to it.

How many of you have kids? Are their grades failing? Root cause analysis! You can even apply it for that. I’ve talked to people about how you can apply this in almost every situation where you don’t know the solution. How many of you have worked for a company where you don’t know the solution? Don’t know the root cause? This is why companies implement this because they want their people to step back, don’t jump to solutions – analyze the data. Although we all know that our managers are sometimes the ones that jump to solutions, right?

Lean and Six Sigma used to be sort of separate initiatives if you will. Lean started at Toyota in the 40s. Six Sigma started at Motorola in the 80s, and just recently they’ve come together now to become a combined tool kit. So if I had to explain in a few words what the difference is between Lean and Six Sigma:

• Lean is really about identifying and wasteful activities and gaining speed in the process. What is really called NVA (non-value add) to the customer – and how do we either eliminate or minimize that out of the process. And what’s really value-add? Are we measuring those things and are we actually making an improvement. If we don’t know where we are with those things, what can we do to make improvements.
• Six Sigma is more about identifying root causes and controlling variation and defects. So a different set of tools, and again, to simplify – it’s really about tools do you need to use out of your toolbox.

Here’s an example of some of the tools you might learn in Lean: Gemba walk, value stream map, standard work, cell layouts, one-piece flow. If you don’t know these things, its OK, that’s why you might want to get more information on Lean, but these are all very valuable tools that come from the Lean side of the house of process improvement.

Then we’ve got things on the Six Sigma side like swim lane maps, measurement systems analysis, histograms, root cause analysis, fishbone diagrams, design of experiments. How many of you guys have heard or used some of this stuff before? Look at all those hands! See!

The common goals really are focusing on the customer. That’s one of the really nice things about this. A lot of people think that Lean mean that less employees are needed. So not true! I love my job and I would not love if it were eliminating jobs. What it’s really trying to do is cut the stuff that is really unnecessary and so that’s what these tools are for – eliminating the NVA (non-value add), reducing variability.

Variability is inconsistent processes. How many you have been a customer of an inconsistent process before. Anybody every try to get a loan modification? Don’t do it! Oh maybe you’ve had a good experience! Here’s a good example: how many of you go to McDonalds for the food? We go there because it’s fast, it’s quick, we know what we’re going to get, lots of minimized variation. Our cheeseburger will be the same no matter which McDonalds we go to in the entire country. Same with Starbucks, they have really good consistent processes. How many you have ever worked at Starbucks? They have lots of processes and standardization.

Increasing speed, reducing errors and ultimately becoming more profitable. It’s just expanding your toolkit on how to do that.

What is Six Sigma? These are your sigma levels on the left – you’ve got one sigma, three sigma and six sigma for example. In the middle is DMPO – that stands for defects per million opportunities. Then you’ve got your yield over here – 99.9997%. So if you have a process that is Six Sigma, that means you have only 3.4 defects per million opportunities.

I’ll give you an example. Let’s say you run a call center, and your goal is that every call will be answered in less than one ring. If that process is Six Sigma, that means out of a million calls, that means only less then four calls will not be answered after one ring. That is a Six Sigma process. That’s pretty high quality, right? Three sigma, obviously not so good.

The best example that I like to give as far as practically as far as Six Sigma and three sigma is the airline industry. How many of you travel? How many of you have heard that traveling by air is the safest way to travel? How many of you believe that? Let me as you this – how many of you feel confident that you will arrive at your destination alive? Pretty good, right? So it’s actually better than Six Sigma! If you get on a plane you have better than a 99.9997% chance of making it to your destination alive. So you should feel really good – it’s very low probability that this will happen. As a matter of fact USA reported that nobody died on any airline last year.

However, the airline luggage process – is not a Six Sigma process. It is a lot less than that. Which one do you think it is? Sadly it is three sigma. It’s still in the 90s (%). What this means that out of a million pieces of luggage, they will lose, misdirect, mishandle or it will not arrive at the same time as you 66,807 times. So how many of you have had a bad experience with your luggage? Look at that! How is it possible that it’s only this many times that this many people have had that bad experience? Sometimes people travel a lot. Take a look at this – how many pieces of luggage come through LAX in one day? We’re talking millions just at that one airport. So just magnify this 93% / 66,807 pieces of luggage over and over and over, we’re talking millions of luggage. That’s why it hurts, that’s why we feel it because of that defect.

Do you all feel more comfortable about what Six Sigma means? Pretty high quality, right? OK. Sometimes quality is the reason why people do it, sometimes it isn’t. We’re going to talk about that. These are the people that I’ve just helped. There are lots of other companies that are implementing Six Sigma. How many of you know companies that are using Six Sigma programs? Sometimes they call it process excellence. Sometimes they call it operational excellence. There are lots of different names for it because some people don’t like the name Six Sigma because people ask, “What’s Six Sigma?”

Why Do Businesses Use Lean Six Sigma?

Here are some of the reasons. I’m going to talk briefly about why companies want Six Sigma and why it’s been at the forefront of many companies – especially large companies, but small companies can do it, too. Back in the old day, if companies wanted to make more money, all they did was they’d take the selling price and they’d increase it, right? What’s wrong with that today? Too much competition, you cannot get away with that. You’re going to lose business very quickly. You’ve got savvy shoppers, savvy consumers, they’re not going to put up with it. So now the strategy is that you can’t increase the selling price – if you want to more profitable, you’ve got to take it out of your cost to produce – operating expenses. Six Sigma does that. Lean and Six Sigma do that. They are vehicles to reduce operating costs and it’s not necessarily to eliminate people. It’s about looking at the process and asking what can we do to minimize waste.

I ask companies ask, “Why are you doing this? Is it to cut heads? “Cause I’m not your girl if that’s what its for. Do people become more streamlined? Do they need less people sometimes? Absolutely, but what do you do with those people and what’s the strategy? If you do a Six Sigma project and then got a laid off, what do you think’s going to happen when you try to do a Six Sigma project at the next department? Nobody’s signing up for that project. That is not the goal.

This is another reason why companies want to do it. This is the reason Jack Welch wanted to implement it at General Electric when I was there. Traditional quality cost – the cost of poor quality is expensive. It’s actually more expensive to have poor quality than good quality. They say said about 10% of sales revenue is related to the cost of poor quality. That’s just the stuff you can capture. The problem is that not all waste is captured. Its embedded or buried somewhere in cost of goods sold and you can’t capture it. So in essence, really, additional cost of cost of poor quality can equal about 35% of sales.

Let’s think about that – if you’re a million dollar company, what’s 35% of your sales? $350,000 is kind of a lot of money. It can be a big amount of money. At GE, it was in the billions of dollars. Just take any company, maybe you’ve worked there, maybe you know they have really bad quality. Even if you gauged it at 20%. Things are really hard to measure like change orders or re-tooling or expediting. How many of you have worked for a company that’s said “gets the out to the customer now, whatever it takes!” Expediting costs money. Setup slow processes, late deliveries – “I’m sorry we screwed up, here’s a free product.”

All that stuff’s waste. Cost of poor quality. So, how do we get rid of this because if you minimize the waste, you’re going to improve how much you make in terms of profitability? Those are the big reasons why companies want to implement it.

Here are some of the benefits – ultimately drive profitability, but the nice thing about Six Sigma is that it focuses on the customer. It says that if you’re going to improve processes, what is your customer want? And design those processes around what the customer wants first. That’s really important. Being balanced, being efficient and effective is a big goal of Six Sigma. How do we be effective in the customers’ eyes and be efficient in the pocket book by giving them what they want inexpensively.

Most companies feel like they have to do either or. Either we can make a lot of money – OR – we have to satisfy our customer. You can do both! But you have to be very strategic about what is important in the processes to get that balance.

Empowering employees is a big deal. You can’t “do” Lean Six Sigma to people. They have to want to do it. The only way to do that is collaborating with people, not telling them.

Gaining a competitive advantage and then not jumping to solutions in another benefit. Those are some of the reasons why companies want to implement Lean Six Sigma.

Why You Should Care About Lean Six Sigma

So why should you care? Yes, you want to save companies money – that’s great. But why should care individually about process improvement? You can make more money! I don’t have any statistics but Black Belts can make anywhere from 65k to 85k, Master Black Belts can make anywhere from 90k to 130k. Green Belts usually have a regular job so you don’t really see that as much.

Here are some interesting statistics – the U.S. Department of Labor estimates that today’s learners will have 10 to 14 jobs by the age of 38. So, no longer do we have a career for our entire life, so that’s kind of compelling. The top 10 in demand jobs in 2010 did not exist in 2004. We’re moving in exponential times, things are moving quickly; jobs are being created – high paying jobs too.

The amount of new technical information is doubling every two years. For students starting at a 2-year technical degree, this means that half of what they’ve learned their first year of study will be outdated by their third year of study. I’m not showing this to depress you. What does this really mean? We’re moving really quickly these days. How as an individual can you prepare for that kind of movement? We’re currently preparing students for jobs that don’t yet exist, using technology that hasn’t been invented in order to solve problems we don’t even know are problems yet. This is very, very important. It should be a part of your decision making.

What does this all mean? We live in exponential times. The only thing that is constant is change. Dealing with change will never become obsolete; process improvement is about changing things, making them better and the cycle of continuous improvement. There will always be problems, you’ll always need to find the root causes to problems, that’s never going to change. It is not the strongest of this species that survive, nor the most intelligent, but the one most responsive to change. Put that in your pocket!

Pick something you’re going to use no matter what you do, even if you’re a mom. You can use process improvement – it’s nature of the beast, it’s the nature of our world.

Presenter: Tracy O’Rourke of Catalyst

Lean Six Sigma (LSS) is a system designed to increase efficiency and enhance effectiveness in an organization. Can it work in County Government? Yes, it can, but it may be met with a few obstacles. I believe implementation of Lean Six Sigma in government agencies can make a huge difference in employee morale, customer service and the development of efficient processes. The question is, can Lean Six Sigma infiltrate government bureaucracy? Has government dug itself in so deep in inefficiency by adding unnecessary processes on top of unnecessary processes that it cannot see clearly anymore?

Personally, I don’t think it has, but it will take a few dedicated Department Heads like Mr. Dean Logan of the Los Angeles County Registrar-Recorder/County Clerk’s (RR/CC) office to make a major impact. It will take leaders who are not afraid to shake up the system and sometimes take a step backward to move things forward. Leaders who will really look at the root causes of inefficiencies and not be afraid to admit that mistakes have been made.

This article will touch on some of the ups and downs of Lean Six Sigma implementation in county government that I experienced while working on the process improvement team at RR/CC. I believe it may provide some of the reasons for the lack of true efficiency, poor customer service and low employee morale and motivation.

A Case Study In County Government

Getting Started

The RR/CC was experiencing a 17-day backlog in processing mail-in requests for birth certificates. A basic description of the steps of this process was as follows:

1. Mail picked up from mail room
2. Mail opened, sorted and assigned
3. Birth record processed
4. Birth record mailed to the customer

Seems simple enough… right? Well, not quite!

One of the tools used in Lean Six Sigma is to conduct a GEMBA walk, which is a Japanese term meaning, “go to the place.” With the assistance of a certified Lean Six Sigma consultant, Tracy O’Rourke of Catalyst, that’s exactly what we did. We went to the place where this process was being done to see each phase. Another tool of Lean Six Sigma is to comprise a team of experts, not management but people who are none other than the people who actually do the work. A representative from every step in the process participated in a process walk to see what actually happened to these requests as they came through the doors of the RR/CC’s office. Suffice it to say… we were all stunned at the actual process.

Digging Deeper

Let’s dig deeper into the process to find out why!

1. Mail pick up.

Staff performing this function was physically located on the 1st floor of the building and traveled to the 5th floor to pick up the mail. The mail was then taken to the basement for envelope opening, counting, sorting and batching into stacks of 50. After the opening, sorting and batching were complete, the mail was packed up for delivery to the 1st floor.

2. Mail opened, sorted and assigned.

Once received on the 1st floor, the contents of the envelope were removed and analyzed to determine if it was an actual request for a birth record and if so that a payment was included. Requests were then sorted as “GOOD” OR “RETURN”. The good were re-sorted into batches of 50 and the bad were re-routed. The supervisor then assigned the new batches to cashiers.

3. Certificates processed.

This part of the process included processing the payment by entering the payment data in the system and requesting for the document to be searched either online (current birth record) or offline (older birth record). After the record was found it was either printed or copied onto certified paper and then assigned to an embosser to affix the official county seal on each birth record.

4. Certificate mailed.

Finally, the document is assigned to staff who then stuffed the outgoing envelope and placed it in a bin to be delivered to the 5th floor mailroom for mailing to the customer.

Approximate processing time:

• 1 to 1.5 hours to retrieve mail and open
• 30-60 minutes to extract documents and batch
• One minute per document for data entry
• 5-10 minutes per document to cashier
• Other staff assigned to embossing, stuffing and mailing documents
• Staff were also assigned other duties (telephone, kiosk) which interrupted mail processing

Although there were approximately 25 staff assigned to processing an average 331 requests per day (approximately 13 requests per person per 8 hour day), the wait time for customers was approximately 30 days.

One of the goals of Lean Six Sigma is to eliminate waste. The 8 Wastes of Lean are:

1. Transportation- Unnecessary movement of materials around the organization
2. Inventory- Any supply in excess of one-piece flow
3. Motion- Any movement of people that does not add value to the product or services
4. Waiting- Waiting for man, machine, materials, information, etc.
5. Overproduction- Making more earlier…faster than the next process needs it.
6. Over-processing- Effort that adds no value to the product or service from the customer’s standpoint.
7. Defects- Information, products and services are inaccurate and/or incomplete.
8. Underutilized talent- Not utilizing people’s experience, skills, knowledge or creativity

7 out of 8 Wastes of Lean were identified in the mail-in birth record process!! They did not have excess inventory.

Implementing Improvement

The plan to decrease processing time and provide faster, efficient customer service was simple:

• We created one-piece flow as much as possible to eliminate the multiple handoffs, duplicate batching, sorting and counting. Instead of handing the document from one person to another to complete steps in the process, one person is accountable for the entire transaction. The average processing time per document was 6.52 minutes. An employee working an average of 6 hours per day could process 54 documents. What a time savings!
• We relocated the person responsible for picking up the mail on the 5th floor, taking it to the basement to process and then packaging it all up and delivering it to the first floor for process. He is now housed on the 1st floor, goes to the 5th floor to get the mail and returns to the 1st floor to process it. No unpacking and re-packing. No duplicate batching or sorting. Just pick up and process. You’d be surprised at the amount of time saved.
• Lastly, four employees were loaned from another division to help eliminate the backlog. Within 2 weeks the backlog was gone.

The Results

• After process mapping, brainstorming and analyzing data, we implemented a plan which took half a day to put in place and in a few weeks reduced the processing time from 17 days to 1 day. Yes, only 1 day!
• Staff assigned to the online process was reallocated to the offline process which reduced the processing time for that operation from 3 weeks to one week.

They have been able to maintain this level of service for over six months now.

So what were some of the ups and downs we encountered in initial application of Lean Six Sigma?

The Ups We Encountered During Our Lean Six Sigma Application

1. We had buy-in from top management upon inception.

In fact, it was the Department Head and Chief Deputy of the department who had the desire and courage to seek an improvement methodology such as Lean Six Sigma which led them to bring on a consultant and actually assign staff to learn and implement LSS. This, I believe, was vital to the success of the program. The Department Head of this agency eats and sleeps efficiency and was determined to run a more efficient and customer friendly operation. Mr. Logan made sure his top managers were briefed on LSS methodologies which opened the door for the team to take action.

2. A successful LSS program relies heavily on subject matter experts.

Who better knows the process and ways to improve it than those doing the work? Our battle was getting them to open up after they had been shut down for so long. One manager even stated “we are in the business of lines, that’s what we do, that’s how we save your jobs”. Inefficiency and poor service saves jobs, but somehow that just doesn’t sound quite right. To be included in the process improvement was like a warm embrace for the staff doing the work. After a while they started pouring out suggestions. Subsequently, they made other improvements in their area and continue to seek improvements. It was infectious. People really do want to work smarter, not harder. No longer were they just employees, they were part of the team a member of the organization and they were proud!

3. Accountability and pride of ownership increased.

With one person being responsible for processing a document in its entirety, there is accountability. As staff gained knowledge of the entire process their skill level increased. As one employee put it, “Now I can do it all”. It is their signature on the record they are mailing out, they handled it all, not just a piece of it. They personally make a difference.

4. Staff development increased.

With the backlog eliminated staff are able to devote time to other projects and improvements. One employee stated that she now has time to do special projects for management and it felt good to be caught up. They actually have time to think about other improvements. And they have! Management has learned to listen and staff has been freed to think and suggest.

5. Customer satisfaction.

Positive letters from the public are few and far between in the public sector but one customer stated that she greatly appreciated receiving her son’s birth certificate in one week of her mailing the request. Although the website indicated that it may take up to 30 days, she mailed her request on a Monday and received the processed document in the mail on Saturday. Customer service should always be this timely and efficient.

The Downs We Encountered During Our Lean Six Sigma Application

Throughout the implementation process we noticed some areas that greatly impacted efficient operations in government. These are not walls that RR/CC faces alone but are seen throughout many county government departments. They do not stop the process of continuously improving but may have some impact how quickly an improvement can be realized.

1. Resistance to Change.

For most people there is a general resistance to change. Skepticism and reluctance to let go of the old way of doing things. It was very important to meet with staff first to ease their fears and let them know that we were there to look at the process and not the people. This had to be reiterated multiple times.

2. Work Measures.

Employees were not governed by any measure of productivity. Someone can process 10 documents and another can process 30. There really was no way to measure productivity and line management seemed to be reluctant to even discuss the issue because of possible union involvement. There has to be some medium ground to determine an average number of documents a person can process in a day, hour or week. Work measurement not only gives management a tool to accurately appraise performance but it also gives the employee a goal, a vision, something to strive for. People perish with no vision. No wonder there is so much complacency in government; there is no level of excellency to strive for. What do we value as an organization? Quick processing? And exactly how do we quantify “quick”? Do we value customer service? How do we know the level of service we are providing if we don’t have measures? When we completed time studies to determine the sustainability of the improvements we found that on average staff could actually process an average of 54 documents per day. With current staffing levels they could process 1,350 documents per day. On average, 331 documents were received per day.

3. Excessive Employee Absence and Restrictions.

Although the mail processing section had more than enough staff to process the requests timely, they experienced a high volume of employee absence and restrictions due to medical reasons. Although programs like the Family Medical Leave Act (FMLA) was designed to help employees keep their jobs when faced with medical restrictions for themselves or close family members, it sometimes cripples government agencies by reducing productivity. They can be granted up to twelve weeks off work and the only criterion is that the worked at least 1,250 hours in the previous employment year. When a person goes out on FMLA or has some form of restriction, the work still has to get done. That position is in limbo until the person decides to come back to work or leaves. So what do most agencies do? Create and justify another position. The work needs to get done. Maybe there should be some criteria for the privilege of FMLA, such as review of attendance and performance records to determine eligibility. I don’t know the solution and understand that these policies were put in place for a reason, but the criteria may need to be re-visited.

There is definitely a loss of productivity due to the unknown work schedules of staff who are on Restrictions, Medical Leave, FMLA and any other policies allowing extensive time off from work.

The column indicating 25 staff includes those under FMLA. The loss of time indicates hours.

The column indicating 19 staff does not include those under FMLA. They are not factored into the productivity loss at all.

4. Changing Processes Without Data

We also noticed that some processes were changed because of a complaint without really looking into the root cause of the problem. In another instance an entire new section was created, but the same problems existed. An additional day of processing time was added which created a delay to the customer.

Conclusion: Lean Six Sigma Can Work In Government

In spite of the downs we were able to make some very positive and effective improvements. There were barriers, but not mountains. Barriers can be removed or circumvented to get to the desired end.

Can Lean Six Sigma work in government? ABSOLUTELY! I think it is a very valuable tool. There are many processes in government that can be streamlined to operate more efficiently. Some very important tips that I learned throughout this process are:

• Get buy-in at the top level; build teams at the working level.
• Don’t overreact to errors. Government agencies need to be careful not to overreact to a complaint and to really utilize the tools of LSS to find the root cause. If it is a one-time occurrence and the process works, it was simply an error. These will happen occasionally. Even Six Sigma allows 3 defects per million occurrences.
• Focus on the customer.
• Create a Vision. Work measures are vital for employees and agencies. How do we get to where we need to be if we don’t have a clue where that is or where we are?
• Dedicate staff and/or hire an outside consultant to get the ball rolling.

Remember, there is always room for improvement!