February 4, 2013
The Lean Virus has hit the Federal Government….Kaizen!!!

By Mindy Hangsleben (@MindyHangsleben), External Fellow for the Clinical Quality Measures Project

We just finished an amazing, exciting, empowering Kaizen (continuous improvement) Event focusing on leaning out the electronic clinical quality measurement development cycle.  Stakeholders gathered from all parts of the process to “map it like it’s hot” for a full 5 days…and believe me they mapped it like it was hot.  The event included folks all the way from federal employees to EHR Vendors.  With over 100 attendees, most of which had never participated in an event like this, we had 8 different scopes where we mapped out the current state of process, defined our ideal state, and then built our future state.  The current process timeline takes anywhere from 3-5 years and is filled with defects with our future state we hope to knock this down to 1 year and a large reduction in defects.  Throughout the process we were excited to uncover the horrors of our waste which included crazy amounts of re-work and multiple layers of sign-off causing significant wait time.  Not only did we uncover the horrors, we also learned about different roles throughout the process.  Many folks commented about how they didn’t realize that the other person had the same inefficiencies within their processes.  In Lean we always say bad systems beat good people, most of the time we don’t understand what others processes are and we tend to blame the people before looking at the system.

Throughout the event we shared our a’ha moments with our Senior Leaders.  It was a true reflection of how folks from different strokes can come together and really make things happen.  A couple that really resonated with me was when the HHS CTO joined us and a contractor stood up and shared how empowered she felt and the excitement around collaborating to enable the future state process.  Another external participant shared how for five years she has been dealing with enormous amounts of waste and frustrating processes and she finally felt like she was heard and now there is hope that it will be fixed.  Can you imagine working in an environment where change seems so impossible that you are always stuck banging your head against the wall?  Believe me, I have never worked in a place where I have felt so landlocked by restrictions and policy that even doing the smallest things like trying to hold a meeting with external stakeholders took me two months of very, very persistent follow-up and trying to  get approval even when the funding was ridiculously minimal.  Remember no free lunch with the government like the private sector. image

Personally, I could have never held this event without the support of Senior Management at CMS, ONC, the Secretary’s Office and the two Lean expert trainees.  Out of the senior leaders, two of them, who are very dedicated to this process, spent all week with us mapping and busting rocks.  That being said five days is a huge time commitment and this really shows how all parties involved are ready for change and are committed to making it happen.  In addition, the two lean experts were phenomenal and saved me quite a few 12 hour work days.  Last but not least the participants were amazing and so open to learning the process and working to remove waste. 

There was so excitement and energy from the group.  Usually these events are so draining that most people are dragging by the end of the day…not this bunch! 

On our final day of the Kaizen we held an optional networking lunch before folks flew back home.  It was crazy how many people showed up, I thought most would have been drained from the 5 days but they still had a ton of momentum and energy.  As I sat at lunch I observed how many relationships had been built over the week and could feel the empowerment.   I even had one group approach me with a picture of a mapping they had put together when they were out one night.  They were working on Leaning out one of the participants dating process.  How funny and touching at the same time…in the back of my mind I was asking myself is everyone was carrying around mapping supplies after hours, what have I done to these people???  There goes the virus spreading again, hopefully it moves as fast as the flu.  One by one folks continued to approach me and share their excitement and feelings of empowerment.  I believe this is the first time in the federal government that anyone has taken on such a task.  If any group can get er done I believe it is this one.  I can’t wait to implement all of the great work everyone did.  I will leave you with one final note never underestimate the power of the post-it!!!  Great job everyone!  If you attended please share any stories or reflections by selecting the comments below.

December 28, 2012
Map it Like it’s Hot!!

By Mindy Hangsleben (@MindyHangsleben), External Fellow for the Clinical Quality Measures Project  

As I head back to MN to celebrate Christmas with my family I have more than just the holidays to celebrate!  This week we experimented with bringing together CMS and ONC to do some pre-Kaizen Event activities.   For those of you who are unfamiliar with lean, a Kaizen Event is where you basically overhaul a process by getting everyone together in a room and map it like it’s hot.  This visually represents the process and allows an objective view point to make sure your future state process is more efficient and higher quality.

We were trying to move fast as you all know this is government and I only have 12 months to make a difference.  With the organization being mostly new to the lean concepts I knew if we waited until the big Kaizen Event at the end of Jan that it would be more of me teaching and not a lot of process re-design happening.   I was very nervous as this would be the first place where I could get a good idea if the lean thinking culture shift was going to be a difficult one or rather smooth.  One of the key things to creating a culture shift is that your management has to be on board not only them saying it but also demonstrating presence and commitment. I only slept 3 hours the night before the event.  

One of the biggest challenges I personally face is teaching to new organizations.  It’s hard for me not because I don’t know the material but because I want to make sure that everyone gets something out of what I am teaching.  Unfortunately, you will usually run into some nay-sayers that don’t believe lean will work and I have a hard time not trying to spend extra time on them to try shift their thinking.   I was surprised it was awesome!   Out of the 25 people that we taught lean to, all of them were excited and willing to learn, at least that is the impression that I got! J  

During the event we mapped out the current state process of the quality measure development.   I call this mapping it like it’s hot.  The team did a great job, it really opened everyone’s eyes to how much opportunity there is to eliminate waste!  I think one of the big ‘a-ha’ moments was two steps one right after the other that had the same 4 approval loops…not to mention all the wait time for these approvals was taking anywhere from a day to a week.  That being said just the approvals could take up to 4 months…WOW…painful J

On a side note we had exceptional participation from the CMS senior leadership. They were supportive by demonstrating their commitment through their presence and willingness to look honestly at the waste.   They even reviewed a list of what we called out Big Hairy Audacious Goals (BHAG’s) and committed to helping us out with them.  I already received emails that are getting the ball rolling on a few of them.   More to come!  Happy Holidays   

December 17, 2012
Welcome to the Federal Government!

By Mindy Hangsleben (@MindyHangsleben), External Fellow for the Clinical Quality Measures Project  

Where to begin, as I am very behind on my blogging…I promise to be more diligent in the future!!!   Also I would like to fully disclose that I went to engineering school because English and creative writing was not my forte.  If there is a place for public comment I am guessing my brother-in-law will help correct my grammar errors. J

A little background on myself, I am originally from the Minnesota/North Dakota border just an hour south of Canada, so yes you may read this with a strong Midwest almost Canadian accent.  I earned my Bachelors degree back in 2005 in Chemical Engineering from the University of North Dakota…”Go Sioux”.  Since college I have been working at Intel Semiconductor in Oregon.  I started as a Process Engineer working on the production line making computer chips for 5 years and then over the past 2 years I had the amazing opportunity to work on two Lean start-ups.  One of them I traveled around the world training Product and Test Development Engineers in the assembly test factories, and the other working with our Healthcare Marketplace Collaborative in Oregon.  For those of you unfamiliar with Lean in essence it is a set of tools used to remove waste out of a system to deliver the most value from a customer’s perspective.  

When my upper management approached my group with the HHS Innovation Fellowship opportunity I knew that it had been written for me!  This fellowship would enable me to work on my top two passions, one creating pay for value healthcare in the US, and the other, leaning out systems empowering employees to make their work environments better!!   About a month ago I packed up and moved out to DC leaving behind my 8 week paid sabbatical that was scheduled to start the day I left Oregon.  Some say I am crazy for giving that up but what would I do with 8 weeks of time off when I could be changing the world? 

The DC area is great.  I left my truck back in ND so I am vehicle less which is a huge change for me.  I now spend extra time and enjoy the atmosphere when I go to Target because of the 3 hour transit it’s kind of like the excitement that my niece and nephew have when they get a piece of candy.   In addition, I am one of the few people here who insist that 40 degrees is not cold, they have since quit asking my opinion on the weather, I guess I steered them wrong a few times.  As much as I could go on and on about my personal experiences I am guessing you want to hear about the fellowship.

The first couple of weeks I was introduced to a lot of challenges and immersed in a very different culture then where I came from, not to mention I went from Jeans to Suits…which yet again was one reason I originally went into engineering.   One of my first experiences at the federal government which has taught me to cringe at the word policy was when I received my new PC a few days into the fellowship.  Exciting times, right?  I saw the Windows7 sticker and was excited because I knew this would bring me all sorts of tools… but…. I quickly realized it had been downgraded back to Windows XP.  I asked the Why and if I could get some of these tools downloaded on my PC and was told it had to do with some sort of Policy/approval process that needed to happen.  Also, as Zac mentioned in his blog the difficulty with the IT infrastructure is like fort Knox.  One of my personal struggles is when trying to work across the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator (ONC) which are both on separate IT systems but yet both part of the HHS; it’s impossible.  As part of my fellowship we are working to lean out the electronic Clinical Quality Measures (eCQM).  About 30% of the eCQM’s are developed by ONC and the other 70% at CMS so you can see why we need to collaborate on our lean efforts.   With the current IT infrastructure, in order to communicate, we have to do everything through email or over the phone, as you can imagine this is a nightmare for document control and makes it hard to know who’s on first and who’s on second. 

Fortunately as part of the fellowship we have a great support system from the Secretary’s Office.  I highlighted to the CTO for the Secretary who is sponsoring our fellowship that these tools would greatly impact the success of my fellowship.  He immediately scheduled time to meet with the other fellows and myself to help address our IT needs and was able to provide a solution path and connect me to the right folks to hopefully get a solution in place soon!!! 

A couple weeks later I ran into yet another policy obstacle trying to get approval for holding a Kaizen Event with feds and non-feds to create a defect free and streamlined eCQM process.  This is a non-trivial task in the private sector but not so much in the government.  Due to multiple policies in place there are certain rules and approvals that need to be completed.  This would take months to get through everything and I only have 12 as part of my fellowship.  Even if we wanted to hold a meeting where we pay for nothing this still is a violation of policy…I won’t bore you with the details but I do need to mention that every meeting hosted by the government I have never had breakfast or lunch provided as part of the meeting/conference.  This is the exact opposite from what I experienced out in the private sector.  This isn’t a huge deal but it was an “a-ha” moment for me as I was always under the assumption that the government spent money on frivolous items such as this.  I was definitely wrong on that one!!

I am happy to say that I believe that we have found a way to get the approvals and necessary documentation by working diligently with management in CMS/ONC and the Secretary’s Office to make this happen.  I have been very surprised and grateful for all the support I have received thus far. 

I am going to close on this note as I myself am starting to feel that this blog post is long enough.  I still have so much to share and am planning to blog again soon to talk about the beginning of integrating Lean into the CMS and ONC culture and also publish some of our initial Lean activities.  It’s going to be an exciting year and I have the pleasure of working with a ton of talented folks who are passionate about making change thus the being the main reason for why they took government jobs.  They even gave me a Minnesotan boss so we can exchange our hotdish recipes. 

Please email me if you would like to give me feedback on my blog or if you have any questions.  mindy.hangsleben@hhs.gov  Thanks for taking the time to read this. 

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