LEAN DAILY MANAGEMENT:

LEADERSHIP IN THE GEMBA

Eduardo Osorio
Jamie Klimp
Process Management Consultants
WHO IS BRONSON?
 System Statistics
Workforce:
• 7,100 Employees (1,400 RNs)
• 1,000 Medical staff members
• 870 Volunteers

Licensed bed count:

• 648 Acute care beds
• 115 Skilled nursing facility beds
• 49 Psychiatric/gero-psychiatric beds
Bronson’s Service Area
 Bronson Healthcare Group

• Regional, not-for-profit health system

• Serving southwest Michigan since 1900
• Bronson Methodist Hospital-Located in
Kalamazoo, Michigan
• 21,500 discharges and 103,000 ED visits
WHY GEMBA WALKS
 Why Gemba Walks
Leaders tell us they want to:

• Create a culture of problem solvers

• Align organizational goals with
department goals
• Increase employee
engagement
• Bring executives to
interact with employees
 Why Gemba Walks
Front Line Employees tell us:
• “I don’t know how to ask for help”
• “My boss doesn’t know what I do”
• “The left hand doesn’t know what the right hand
is doing”
• “I’ve tried to implement
change but got frustrated”
 WHAT ARE
GEMBA WALKS?
Bronson’s Improvement (EDI) Model
 Lean Daily Management
• Daily Huddles
• Daily Check In
• Gemba Walks (The focus of this
presentation)
This is Gemba
This is NOT Gemba
 Gemba Walks
• Daily (Monday-Friday)
• Along a Specified Route
• Around a Standardized Board
• By an Executive and a Director
• Standard Scripts
Gemba Walk Video
 What do they look like?

Metric Bar
Charts

Pareto Chart

Action Plan

5 Whys
 What do they look like?

Metric Bar
Charts
 What do they look like?

Pareto Chart
 What do they look like?

Action Plan
 What do they look like?

5 Whys
 Gemba Walks
Current State
• 3 Service Lines have
Gemba Walks
• Cardiac (5 Boards)
• Neuro (5 Boards)
• Ortho (6 Boards)
• One Support Service Line
(5 Boards)
• Patient Access/
Environmental Services
(Manager Led)
(6 Boards)
HOW TO CREATE
A GEMBA WALK
 Preparation

• No Meeting Zone (10:00-12:00)

• Executive and Director Training

• CEO to do first walk

 Gemba Walk Standard Script
Gemba Walkers Board Presenters
1.The Executive Rounding Team is led by a
spokesperson. 2. Say “Good morning” to the leader of the Gemba &
state your name and role.
Note: Get right to the report out. You are reporting on the last
24 hours of activity with some exception for weekend items.

3. The spokesperson warmly greets the presenter &

introduces others (including their department/role).
4. Present from left to right on all the metrics.
Example: Our Safety Metric is Patient Falls; Our target is
zero; We are green for our safety metric. We didn’t meet our
Quality Metric, which is Mislabeled Specimens, for the last 24
hours. Our target was “X” and our actual was “Y”. We had an
issue with “Z” (Pareto). We have completed a 5 Why and the
Root Cause is “A”. We have identified __ action item on our
5. Verify a cause been found (Pareto / 5 Whys) and Action Plan.
there is a strategy in place (Action Plan). Review
these on the board and further discuss, if necessary.
Provide guidance and help to remove barriers. This is 6. When this process is complete, ask “Do you have
the critical part that the Leadership team plays in the any questions for me or the team?” If you do not
know the answer (and no one is available) put it on the action
Gemba to
plan to follow up on and available for them to view on the next
Gemba Walk.
7. To conclude, the spokesperson asks: “Do you have
what you need to meet your goals today?” 8. Thank them for coming!
 Walker Key Points

• Red is Okay– Make sure presenters

understand that red shows good problem
selection
• Board purpose = “Problem Solving Tool”
NOT “Report Card”
• Make focus and questions about “Action
Plan” items
 Format

• 4 Day Kaizen Event Format was Used to

Implement Gemba Boards
 Steps to Create a
Gemba Walk

Learn Problem
Solving

Develop Metrics Build Boards

Train Staff Practice Run Final Run

 Develop Metrics

Learn Problem
Solving

Develop Metrics Build Boards

Train Staff Practice Run Final Run

 Develop Metrics

• Staff are given some time to think about

metrics before the event
• Staff are coached in the event to come up
with the original 4 metrics
• Staff are coached after the event when
it’s time to change the metrics

Staff Choose the Metrics

 What are Metrics?
They are grouped into five basic categories:

Safety - Falls, Employee Injuries, PPE

Quality - Documentation, Errors, Right the first time

Delivery - Timely Responses, Correct Information

Productivity - Man hours, Overtime, Idle time

Cost - Delays, Inventory on Hand, Over-processing

 What is more
important?
Safety Patient/Customer and Employee
focused

Quality
Patient focused

Delivery

Productivity
Business Focused

Cost
 Sample Metrics
Cardiac Value Stream -
Area Safety Quality Delivery Productivity Cost
5 days ahead of pre-
registration.
none at this time <5 orders with problems 0 call center scheduling
Call Center none at this time
per day errors
0 accident information
missing
Area Safety Quality Delivery Productivity
Diagnostic Turnaround
Patient Wait Time < 30 Order reconciliation of
abnormal nuclear or echo Zero occurrences of MI
Advanced minutes from sched. Appt Testing Procedures and
within 24 hours to MA Calldown to non-scheduled none at this time
Cardiac to Provider Contact at least EKG's to be marked done
100% of the time provider
50% of the time ECIS 80% of the time
Area Safety Quality Delivery Productivity Cost
Zero Patient Falls
80% of Discharged
100% Documentation of
Cardiology 90% of patients will have patients leave unit within 1 none none
Patient I & O per shift
their sheaths DC'd within hour of order written
30 minutes of normal ACT
Area Safety Quality Delivery Productivity Cost
100% Document Contrast
usage in EPIC
Cath Lab none 80% First Case On Time in No PRU Staff misses
none
& PRU each lab lunches between 12 & 2
100% appropriate Time
Out for All procedures
Area Safety Quality Delivery Productivity Cost
Zero Incorrect Stress
Cardio-
Pre-Stress Check List Orders received 70% of Stress Tests are
Vascular
received prior to test 90% started within 15 minutes of none none
Services
of the time 100% of Patients arrive scheduled time
(CVS)
with appropriate attire
Learn Problem Solving

Learn Problem
Solving

Develop Metrics Build Boards

Train Staff Practice Run Final Run

 Learn Problem Solving
• Training includes:

• 5–Why
• Choosing the right problems
• Brainstorming Countermeasures
• Manageable experiments
Pareto Analysis
5 Why’s Worksheet Date: 2/17/14
Completed by: John, Stephanie R, & Bob

Define the Problem:

The car won’t start because the battery is dead.
Why is this happening? Caution: Don’t
jump to
Why is
1. The alternator did not charge it correctly. Conclusions
that?

Why is
2. The alternator is not rotating.
that?

3. The belt driving the alternator from the Why is

crankshaft pulley is broken. that?

4. The belt was not changed at correct Why is

mileage interval. that?

Caution: Focus on
5. The owner did not follow the
the Why’s NOT the recommended maintenance schedule.
Who’s
5 Why’s
5 Why’s Worksheet Date: 2/17/14
Completed by: John, Stephanie R, & Bob

Define the Problem:

The stone on the Jefferson Memorial was crumbling
Why is this happening? Caution: Don’t
jump to
1. The stone was crumbling because it was Why is
Conclusions
washed too frequently. that?

2. It was washed regularly to remove the bird Why is

droppings. that?

3. The birds flock to the building due to the Why is

abundant food supply of little fat spiders. that?

4. There are so many spiders because they Why is

are attracted to all of the midges. that?

Caution: Focus on 5. The midges are attracted to light and

the Why’s NOT the emerge in a mating frenzy when the Park
Who’s Service turns on the spotlights at dusk.
 Solution:
Delay the daily lighting to one hour after
sunset. Midge population went down 90%,
they have broken the food chain and there
are less frequent washings.
 Build Boards

Learn Problem
Solving

Develop Metrics Build Boards

Train Staff Practice Run Final Run

Build Boards
Build Boards

You will need:

• Post-it packages (2)

• Sign Holders (12)
• Screwdrivers (1)
• Screws (27)
 Train Staff

Learn Problem
Solving

Develop Metrics Build Boards

Train Staff Practice Run Final Run

 Train Staff

• Staff Training Staff

• Employee Roster ensures
100% Completion
• Different Levels of
Training
• Observer
• Apprentice
• Expert
 Practice Gemba
Walk

Learn Problem
Solving

Develop Metrics Build Boards

Train Staff Practice Walk Final Run

 Practice
Gemba Walk
 Final Run

Learn Problem
Solving

Develop Metrics Build Boards

Train Staff Practice Walk Final Run

Final Run
 PDSA
(PLAN DO STUDY ACT)
 PDSA
(Plan Do Study Act)
• SharePoint
• Gemba Board Owners
• Action Plans moved under
Metrics
• Week-long commitments
• Process Management Support
on Mondays
• Maps available in
the meeting area
• Manager led walks
are successful!
 Upcoming Thoughts/Changes
• Incorporating Bronson
Practices
• Develop devoted team
problem solving time
• More coaching through
managers
• Identifying organizational
metrics related to the
boards
• Including Patients and
Family Advisors on the
walk
Sample Results
Orthopedic Gemba Walk
 Thank You!

bronsonhealth.com