Reflections on Hoshin Planning: Guidance for Leaders and Practitioners

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  1. Address complex business issues
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  4. Reflections on Hoshin Planning | Guidance for Leaders and Practitioners | Taylor & Francis Group

The evidence of a consensus decision is that once it is made, everyone who participated in making the decision begins to behave consistent with the spirit of that decision. The results of a Hoshin plan are influenced by whether consensus is achieved along the course of its selection and implementation. One means for arriving at consensus is the dialogue that takes place to create an objective measurable definition of success.

Leadership focus, and openness to learning what monitoring metrics give the best indicator of business success as the Hoshin work advances, helps keep plans real and improves results. Integrating Hoshin metrics with business fundamentals. Hoshin Planning aficionados sometimes take some teasing for being overly fond of fancy matrices, but some way of showing how all the measurable goals and activities of the organization are related is essential.

Senior leaders need to create a visual that shows how their business, Hoshin, and operational goals impact and support each other. Has Hoshin planning been successful in your organization? Has flexibility been a problem? Gaining expertise in Lean activities also provided opportunities for those not in formal leadership roles to gain some recognition as an informal leader. Implications for Future Research: Lean program theory proposes that use of a common set of Lean tools will ensure consistent quality improvement processes and practices across the province, which will in turn generate distributed quality improvement knowledge, thereby generating improved decision-making ultimately leading to better quality of care.

It further proposes that providing leaders with training in the use of all Lean tools will allow them not only to choose the right tool for the job, but also to use multiple tools simultaneously to generate quality improvement synergies. Experience in use of the tools will improve skills in inclusive leadership, while experiences of success will build belief in and commitment to the Lean approach, contributing to a virtuous cycle. A realist evaluation will investigate to which, and the circumstances in which, this program theory plays out in practice.

Leaders who value the structure Lean provides are more likely to trial a wider range of tools.

As a result of trialing more tools, the leaders are more likely to achieve success in meeting their objectives and therefore more likely to establish the virtuous cycle. Leaders with high levels of autonomy are more likely to choose tools that they believe are appropriate to local issues. In circumstances where there is agreement between different levels of leadership about the more important issues to address, the most appropriate tools are likely to be selected, successes are most likely to be achieved, again establishing a virtuous cycle.

Address complex business issues

Lean espouses particular roles and management styles for leaders. They are intended to develop inclusive approaches that both inform and seek input from all members of teams, thus creating a culture in which it is safe for any staff member to speak up about issues or offer ideas.

i-nexus Hoshin Planning Solution Overview

The importance of having strongly supportive leadership in Lean implementation was clearly articulated by participants. They also muster the human and material resources to the extent of their authority required to support the implementation of Lean initiatives. In discussing the unsuccessful introduction of Lean in a previous workplace, a staff member noted that there had been very little information provided to staff by management. These changed practices by leadership are a critical aspect of the program theory for Lean , not least because they contribute to empowerment of staff to play their intended roles.

Leaders being present at the work site also conveys that they are willing to witness and to participate in the day-to-day realities and demands to which workers are subjected, which in turn can help leaders account for these realities in their own decision-making. However, some leaders reported major discrepancies between implementation processes they experienced and the espoused values of Lean.

They reported lack of clear information even when it was specifically requested, lack of ability to set local priorities, and lack of flexibility to adapt tools to local contexts. Implications for Future Research: We hypothesize that leaders are less likely to adopt prescribed new leadership styles or they may be more likely to revert to previous styles of leadership if they perceive either of the following: a the lack of centralized support to support the prescribed management style: or b the failure of central authorities to accept situations where the leadership style may need to be modified to reflect local contexts.

Leaders commonly demonstrated a high level of commitment to ensuring the success of Lean implementation and felt accountable to do their best, particularly with regards to removing barriers to quality improvement initiatives. The personal contribution of leaders was recognized as critically important to success of Lean , but also more broadly to the salvation of health care in the province. The focus on the individual accountability of each was intensified as Lean was implemented.

This accountability extended to ensuring that those in leadership positions were in fact committed to its implementation. Intense training is provided through Lean which is intended to ensure that leaders have the skills they need for the role and a deep understanding of how the various components of Lean fit together to generate change. However, the very intensity of that training was problematic for some.

In spite of the intense training, some managers still felt unprepared to lead Lean activities.

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While leaders had an increased level of accountability, the resources needed to do the work were not always available, particularly in smaller health regions. Supports such as IT resources to pull required data and team level supports to help run the Lean projects were not uniformly available and created additional pressure on leaders. Several leaders remarked on the lack of role clarity and ambiguous nature of accountability for some activities.

Implications for Future Research: Increased levels of staff and patient participation in improvement activities and increased visibility of leaders all contribute to increasing transparency, which in turn acts to hold leaders accountable for improvement. Our program theory suggests that leaders are more likely to implement Lean effectively, and adopt the desired management styles, when they themselves are empowered, having the appropriate autonomy, information, support, access to resources and access to professional development.

Lean management is predicated on high visibility and better use of better data. It requires leaders to collect and display locally relevant data using techniques such as data walls, and to design quality improvements to address the problems identified through their data. Use of the appropriate Lean tools then means that the causes of safety problems are addressed, which contributes to improved patient safety.

Data also works to hold leaders accountable for safety and quality improvements. Measurement was valued by front line, physician and leader respondents. The data generated through Lean activities was a tool seen by some leaders as a means to promote fairness in decision-making. Leaders also saw the value of measurement in providing irrefutable evidence about why change was necessary to staff and to assure themselves that change was necessary.

Physicians also appreciated, and were reported by others to appreciate, the objective nature of the evidence provided by Lean activities.

New Book Reflections on Hoshin Planning: Guidance for Leaders and Practitioners

This is important because physician engagement was described as necessary for specific changes to be implemented and valued. The importance of physician engagement was highlighted in the Conference Board of Canada survey as a key success factor [ 3 , 30 ]. Engaged physicians encouraged buy-in by others and modelled new behaviors, particularly for other doctors. Implications for Future Research: We hypothesize that leaders will be more supportive of Lean initiatives in a context of timely access to meaningful data relevant to their projects.


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Where data is difficult to access, unavailable, perceived as poor quality or challenging to obtain or collect, leader support of Lean will be compromised. Lean seeks to create an environment in which mistakes are opportunities for learning, with consistent implementation of no-blame approaches to mistakes and errors. Argyris ; suggests that double-loop learning is essential if practitioners and organizations are to make informed decisions in ambiguous and rapidly changing contexts [ 27 , 32 ]. Single-loop learning occurs when people search for another strategy to address the error and work with, or within, the governing variables, so that extant goals, values, plans and rule are operationalized rather than questioned.

Single-loop learning typically follows pre-set routines and plans, engendering less risk for both the person and the organization and affording greater control. Some of the Lean tools, which provide highly structured ways of addressing particular problems in very specific contexts, may be considered to support single loop learning. In contrast, double-loop learning leads to questioning of the governing variables themselves, such that governing variables may be altered and a shift in strategies and consequences occurs.

The underlying philosophy of Lean and the changes it envisages to leadership style, staff empowerment and patient-centered design of services and systems involve learning of this kind. This is more challenging for many people and might be expected to take longer to evolve. Implications for Future Research: We hypothesize that leaders will support Lean to the extent that believe that they are able to make mistakes without negative consequences for their positions within the organization. In addition to the materials on which our program theory is based, the baseline interviews revealed perspectives on a number of other matters which are likely to affect whether, where and how Lean works.

Lean as a quality improvement tool was often favorably compared with previous quality improvement efforts. Past experience with quality improvement initiatives, however, made some leaders wary of investing too heavily in Lean.

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Changes in behavior that are mandated in this case, by workplace expectations that employees participate in Lean activities may lead to situations in which an individual may resolve dissonance by developing a more positive appraisal of Lean than previously held. Over time and with many individuals being exposed to Lean activities, this strategy may foster organizational change. Both reservations — the concern about sustained implementation and that about messaging — reflect the importance of credibility of the program to ensure sustained leadership engagement in Lean implementation. Several respondents had spent vacation time engaged in Lean activities because no other time was available.

Others reported a significant amount of personal time spent working after hours because of the demands of Lean implementation. The high demands placed upon leaders can reasonably be expected to result in changes to their level of engagement and may affect sustainability of this initiative, particularly in the long term. The positive side of rapid implementation was that those who have been trained could quickly implement their skills in Lean projects and see results in a short amount of time.

Leaders who recognize that the changes brought about by Lean have a negative impact on staff workload and morale may be required to invest additional time and resources in supporting those individuals. This would be important to nurture and sustain the efforts of staff to achieving the goals of Lean. Despite the early stage of implementation at the time these interviews were conducted, a number of interviews identified short-term outcomes from the use of Lean tools.

While the implementation of Lean in Saskatchewan is at an early stage, this study has generated initial hypotheses and realist program theory that can form the basis for future evaluation of Lean initiatives. Theoretical work on learning organizations that encompasses the notion of single and double loop learning [ 27 , 32 ] has been valuable in understanding some key components of Lean implementation, although this work may also present challenges, both to the Lean implementation strategy adopted in Saskatchewan or to the program theory we have developed to represent it.

Reflections on Hoshin Planning | Guidance for Leaders and Practitioners | Taylor & Francis Group

As discussed above, Lean appears to involve elements of both single loop and double loop learning encompassing — perhaps — some perceived contradictions. On the one hand, Lean uses highly structured tools and generates highly structured standard work in the local setting single loop learning. On the other, Lean aims to build a culture that is data-based, questioning and reflective, and incorporates a responsibility to challenge peers and authority figures double loop learning.

The Lean implementation process in Saskatchewan similarly incorporates particular tensions: it represents a top-down attempt to build bottom up processes of improvement. This, in turn, creates inherent tensions for leaders. On the one hand, they are required to implement Lean : its implementation is non-negotiable despite any dissatisfaction that it or the lack of additional resourcing for implementation may generate for staff. On the other, they are encouraged to empower staff albeit only in relation to particular aspects of practice and to develop more open and responsive leadership processes.

These tensions are not, in fact, irreconcilable, but they require a degree of sophistication and skill to manage, as well as the establishment of particular cultural mores.


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  6. Background.
  7. Perhaps, however, there will need to be significant changes in both leadership and staff behaviors before such attitudinal and cultural change can be observed. If this is the case, it is likely that change evolves through multiple small feedback loops a small behavior change generated through use of a particular Lean tool generates a small attitudinal change amongst participants, which provides a more enabling context for a next behavior change which enables some further attitudinal change, and so on.

    If this is the case, it has significant implications for the order in which particular indicators of change should be expected and therefore the bases on which progress towards effectiveness should be judged. It also has significant implications for the processes of planning and implementation that should be encouraged to improve patient outcomes in the longer term. This paper has dealt specifically with the changes in leadership associated with implementation of the Saskatchewan model of Lean. Much further work remains to be accomplished in examining the impact of implementation on other key groups, such as front-line workers, patients and families.

    Future challenges involve examining the way Lean is or is not embedded and integrated into health care in Saskatchewan. This research project and manuscript development has been supported by the Saskatchewan Health Quality Council Contract C We acknowledge the financial support provided for this project from the Saskatchewan Health Quality Council, and the help provided by Dr.