Promoting a Model for Excellence

Elizabeth J. Warner, MD, FACP, CPE, has been a practitioner of operational excellence in healthcare settings for more than 20 years. She stepped into her new role as chief medical officer at Cherry Health in Grand Rapids, Michigan, in January 2023.

Her work as coach, consultant, trainer, and speaker through Warner Well Being has supported the growth and development of leaders and organizations through their unique learning journeys. She is a student of the great minds who have developed, distilled, and promulgated this material, including the Shingo Institute.

For the readers who may not be familiar with the Shingo Model, how do you describe it?

The Shingo Model (named after the industrial engineer Shigeo Shingo) is a visual representation for operational excellence. The interplay of components within the model promotes (or erodes) operational excellence for any organization. An excellent summary of the Shingo Model is available for download through the Shingo Institute at (https://shingo.org/shingo-model/ ).

Guiding Principles are at the top of the model. They are universally understood “rules” that govern the consequences of actions.

Systems are tools that work together to accomplish an intended outcome. W. Edwards Deming suggests that “Every system is perfectly designed to get the result that it does.” The Shingo Model reminds us that we can drive, align, and improve these systems to produce better outcomes.

Tools are smaller, single-point solutions to accomplish a specific task. When connected to a larger system, tools can improve outcomes and results. Many improvement teams apply tools such as Kanban, visual management triggers, standard work, and other tools to stabilize and improve tasks.

Results are measurable outcomes based on the application of tools and systems. Key Performance Indicators (KPIs) are often the cited outcomes of operational excellence.

Culture is defined as “all behaviors in an organization.” For a culture of operational excellence to take root and grow, employees at every level know that “it’s not just what you do; it’s also HOW you do it.”

Organizations committed to Shingo Model thinking use Key Behavior Indicators (KBIs) to assess organizational culture and reinforce the long-term visionary focus of enterprise alignment. KBIs might include the number of employee ideas offered and acted upon or the number of patient complaints received and mitigated.

Note that the model is dynamic, with action verbs connecting each of the model’s components. A person never “arrives” at operational excellence, but is flexing, moving, growing, learning, pivoting, adapting and celebrating the journey. Grounding one’s actions in the guiding principles allows leaders to navigate challenges with alignment, humility, and optimism.

What are the guiding principles at the top of the Shingo Model?

The 10 principles that are the basis for building a sustainable culture of enterprise excellence are divided into three dimensions organized as follows:

Cultural Enabler Principles:

Respect Every Individual and Lead with Humility. Without this foundational focus on the people within the organization, excellence remains a distant and elusive dream. To behave according to these principles, the organization must build and strengthen a safe environment for its people, develop them, empower them, and learn from them.

Enterprise Alignment Principles:

Think Systemically. By understanding the relationships and interconnectedness of a system, people make better decisions that will more naturally align with the desired outcomes of an organization.

Constancy of Purpose. An unwavering understanding of why the organization exists, where it is going, and how it will get there. This laser-sharp focus is lived, not engraved on a mission and vision statement. This “True North” enables people to align their actions and improvement work.

Create Value for the Customer. Ultimately, value must be defined through the lens of what a customer wants and is willing to pay for. Living this principle is opaque in American healthcare, with our complex and misaligned payment structures. To be clear, our external customer in healthcare is the patient. Period.

Continuous Improvement Principles:

Seek Perfection is aspirational and references systems and processes — not humans. This principle encourages a culture of ongoing improvement, which is only as clear as the organization’s ability to see and understand its current reality.

Embrace Scientific Thinking. Do this with repeated cycles of experimentation, direct observation, and learning. Many organizations cite Plan, Do, Study, Adjust (PDSA) as their improvement model. Seeing actual experimentation with quantified and testable hypotheses is much rarer. Strategic direction is necessary to guide the experimentation toward the organization’s most important work

Focus on Process. All results are the product of processes. Talented, skilled, caring, committed people cannot produce ideal results with poor processes. Leaders can learn from front-line staff members to improve processes, so employees can consistently deliver ideal results. Leaders must be empathetic with the people but ruthless with the process to improve care.

Ensure Quality at the Source. Perfect quality can only be achieved when every element of work is done right the first time. An error must be caught and corrected before it is passed “down the line” to the next individual/team in a workflow. One example of this is illegible handwritten prescriptions or physician orders. Computer order entry systems were adopted to reduce order errors. While providers may grumble that it takes longer to type in and verify a prescription before electronically routing it to a pharmacy, this tool significantly reduced medication errors because the clinician can verify the order’s accuracy before hitting the “send” button.

Improve Flow and Pull Value. Ideal care happens when it is delivered without interruption. Waste is anything that disrupts the continuous flow of value to the patient. Many improvement teams within organizations help employees and leaders see waste and apply scientific thinking (PDSA) to reduce waste, improve flow, and increase value to the customer.

Physician leaders are often tapped to lead inter-professional teams. What hints can you share about working with a group of clinical and non-clinical employees?

The Shingo Model is elegant in its simplicity. The entire model has only five components, and it can be effectively applied to healthcare organizations. If there is an organizational commitment to the guiding principles, then they are the unifying language in inter-professional team-based work.

Physician leaders who are practicing the Shingo Model as an individual because their organization is not yet committed to a journey of operational excellence can live the principles while applying tools, improving or building systems, and developing individuals in inter-professional teams to achieve intended outcomes.

I recommend physician leaders think explicitly about the task and expectations of a given team. For example, is this a front-line team directly serving patients? If so, what are the tools and systems being implemented to serve (deliver value) to the patient? What are the current outcomes/KPIs? What are the ideal results? What is getting in the way of achieving these results? Where is the voice of the customer (patient) heard and amplified within this team?

This reflection may require some real soul-searching regarding the team and its ability to achieve expected outcome(s). When physician leaders have clarity regarding team tasks and resources, they can collaborate with other members (clinical and non-clinical) to deepen, refine, and expand this understanding and better serve the patient.

Alternately, if the physician leader is in an inter-professional team at a higher leadership level, then the Enterprise Alignment principles of Thinking Systemically or Focus on Constancy of Purpose may be most influential in team discussions. At this level, the team may need to understand how competing priorities at an organizational level deploy throughout the layers of the organization to impact individuals (positively and negatively) who directly deliver value to patients.

If the entire executive leadership team is Leading with Humility, they can more clearly see what is actually happening, and can improve the strategic effort to support the people who deliver value. This usually requires the executive team to be ruthless about minimizing strategic priorities and maximizing going to see what is actually happening in the workplace.

How can the Shingo Model improve patient care?

There are hundreds of examples of healthcare organizations applying the guiding principles within the Shingo Model for patient benefit. PLJ has several case studies of improvement successes in its archives.

There are just as many examples of organizations that have failed to sustain improvement, often because leaders did not change, shift, and grow with the spirit of a learning organization. The Shingo Model is a way of thinking, a comprehensive operating system for the dynamic, human ecosystem of a healthcare organization. It cannot be considered a project, a department, or “someone else’s job.”

If the leadership team in a healthcare organization has provided sufficient clarity, then the organization will have pillars of value around which employees can organize their work and improvement efforts.

These areas of focus may look something like the following, adapted from Andy and Me and the Hospital: Further Adventures on the Lean Journey by Pascal Dennis (CRC Press, 2016):

• People Safety and Development (encompassing the psychological and physical environment for employees)

• Patient Safety and Quality

• Service Delivery

• Affordability

Focus areas (ideally no more than four) must be the most important areas and crucial for the success of the organization. They are listed in order of priority, and “improvement” in one area cannot erode the effectiveness of another area. For example, improving a cost in the Affordability category cannot undermine People Safety or Patient Safety/Quality.

Most healthcare organizations do not have this degree of clarity and commitment to prioritization to have a few actionable strategic foci. This is the work of the executive leadership team, and physician leaders have a unique perspective to influence this strategic work.

How might physician leaders share and promote the Shingo Principles and Model with their colleagues?

Physician leaders who practice and experiment with the principles within the systems and use the tools within their respective organizations with intention and vulnerability, will be articulating their actions/practices/experiments with others. Living, espousing, and practicing the Shingo Guiding Principles is the most powerful and effective way to share the thinking.

Storytellling is also important. As physician leaders grow and learn, capturing and telling stories of their learning ignite the imaginations and creativity of others and fuels hope for long-term operational excellence.