Profile on: Jack Billi, Chief Engineer, Michigan Quality System
It often happens that our lean epiphanies occur because of someone we meet who is already on the journey and who inspires us to embark on a transformation ourselves. It is exactly how Dr Jack Billi got his a-ha moment, in 2003, when he attended a talk by Gary Kaplan, MD, CEO of pioneering lean healthcare organization Virginia Mason.
Gary was a graduate of University of Michigan Medical School where Jack works. He had returned to Michigan to give a talk on the early results of Virginia Mason’s lean journey. That night Jack, Gary, and then Dean of the Medical School Allen Lichter talked for hours over dinner about applying lean in healthcare. They walked to the original Borders Book Store – located in Ann Arbor – and Jack bought a copy of Lean Thinking by Womack and Jones. That began Jack’s journey into how to transform an academic medical center using lean thinking.
"I had always been a natural problem solver, but had done it intuitively using my own skills and wits. What attracted me about lean thinking was the idea of a holistic and systematic model of problem solving," Jack admitted to me during a recent phone interview. Once he realized there was a formal science to solving problems, he wanted to learn more. His aim was to bring the lean philosophy to the University of Michigan Health System, the clinical enterprise of Michigan Medicine.
Jack was aware that if he wanted to see his organization develop these capabilities, he’d have to be the one doing it. He realized that he would have to divest himself of some of the management responsibilities that were part of this job at the time, so that he could pursue lean thinking at UMHS. He started to speak to other practitioners around the United States who were making inroads in introducing the methodology in their healthcare organizations.
The initial breakthrough for lean thinking in the organization came when, during a meeting of healthcare leaders in Detroit, Jack chatted about it with a colleague from General Motors, Jan Whitehouse, who described GM’s journey introducing lean and said the company would be happy to help.
Shortly after, GM allowed UMHS to send several dozen managers to their basic lean training class. Then GM loaned lean coaches to UMHS to facilitate the first six lean projects the healthcare organization worked on. Although most of the initial projects ran into the usual problems, these early experiences (both successes and setbacks) inspired people in the organization and created the momentum for scientific problem solving that Jack was hoping for. Jack also told me about how UMHS received "invaluable guidance" from John Shook, Jim Womack, John Toussaint, and many other lean practitioners over the years: "We have benefitted greatly from a decade-long affiliation with the Lean Enterprise Institute, and with the Healthcare Value Network (Catalysis) since its beginning."
The actual journey started with a collaboration among the Quality Department, the Operations Engineering group and the HR organizational effectiveness team – all of them rallying around the same goal. Jack commented: "For the past decade, the leaders of those three groups, along with an organizational psychologist, my administrative partner, and I have met for two hours a week, trying to plot out what experiments would make sense for our complex organization. We have about 26,000 employees and it has become our goal to create 26,000 problem solvers, who take the initiative every day to find and fix root causes of the most important problems, and to teach their leaders how to truly help them."
THE RESPONSIBILITY OF A LEADER
Jack was trained as a general internist and has practiced internal medicine for his entire time at the University of Michigan – almost 40 years. Over the past four decades, he has held a variety of management jobs in the medical school and in the healthcare system, often with a focus on quality and safety. He’s also worked with community quality collaboratives and insurance companies to improve quality, efficiency and costs, and with population health, patient-centered medical home and disease management for chronically ill patients. His current informal title, which he created to describe his role 13 years ago, is "Chief Engineer" of the Michigan Quality System, which he considers an example of pull-based authority.
Jack’s career is as impressive as his attitude is humble. During our conversation, he quickly admitted having been quite naïve early in his lean journey: he thought that lean would be easy to introduce and well received by everyone in the organization. "I learned the hard way that this was not about just changing the way we identify and solve problems, but about changing the way we empower people," he said with a chuckle.
At first, he was attracted to the technical parts of lean (many of us are) and it was only after working with it for a while that he realized the most important thing is who is solving the problems and how we engage workers and managers. Like leaders in other industries, Jack thought himself a good problem solver and was convinced that the best contribution he could give others was to answer their questions and solve their problems – whether they wanted to hear it or not. Commenting on his evolution, he said: "It took me a long time to understand that the most important thing I could do was asking people good questions, not providing answers, to help them to learn how to solve their problems themselves. These days I try to spend more time listening to people, watching them work, and asking them questions. In fact, my objective for this year is to listen more and talk less. I have a long way to go."
This is not something you hear often from senior leaders, but it was immediately clear to me that Jack is working hard to walk to walk: for example, he attends as many daily huddles as he can, to learn about the organization’s real problems (be it equipment, wait times or suboptimal processes). He told me that what he aspires to as a leader is "to be the best learner and best facilitator of learning in the organization" – a Learner-in-Chief. To do so, he encourages others in Michigan Medicine to consistently follow the teaching of Toyota’s Mr Cho: go and see, ask why, and show respect.
BEHAVIORAL CHANGE STARTS WITH YOURSELF
"Gandhi once said, ‘Be the change you want to be in the world'," Jack told me while talking about the initial spark that, in his opinion, ignites change. "Every lean transformation starts with an individual deciding they want to change their way of doing the work and of treating people around them. And, of course, it has to start with me: the only person in the world I can directly change is me."
That observation – that changing ourselves and our behaviors is the hardest part of any lean journey – is something we often hear from practitioners. Jack’s experience seems to confirm this: for years, with the best intentions, he showed his people photos and diagrams of how other organizations solved similar problems including photos of huddles, visual rooms, and other lean artifacts, until he realized that was just another way of telling them what to do. "These leaders own the problem. They must arrive at solutions that work for them. It’s all about the questions, not the answers: What’s wrong with our current situation? What gap are we trying to close? How is the work done? What are the root causes of our problems? What experiments would we like to run and how do we build consensus around them? All questions from an A3. Telling someone what to do sounds like the easy way, but it doesn’t work," he said.
The attitude of traditional management towards helping workers learn and develop their problem-solving skills is an issue that is clearly on Jack’s mind a lot. During our phone call, he told me he often thinks of leadership behavior in terms of motive (does the leader know it is her job to ask questions and mentor, go see, ask why and show respect?), means (does she know how to do it?), and opportunity (does she have the time to mentor? Is there a scheduled occasion for her to do it every day?). You know you are talking with the most enthusiastic lean guy when he uses the three branches of a fishbone diagram to explain leadership!
In Jack’s mind, lean leadership begins with humility – a necessary trait if you are to admit you don’t know as much as you thought you did – and, luckily, it becomes (a bit) easier over time. "The hardest part is to understand that the real way to help people is by listening to their problems and letting them solve them autonomously. After that, the more time you spend learning about the work and about problems, the more comfortable you feel about asking questions," he commented.
As our chat drew to an end, Jack told me that he often uses the practice of medicine as an analogy for lean. Indeed, there are many similarities between the two: physicians perform a history and physical before arriving at a diagnosis and treatment plan; the lean practitioner goes to the gemba to understand the problem and its root causes before deciding what countermeasures to try. Lean coaching and medical training also have parallels: in teaching new doctors, we don’t tell them what the diagnosis is or how to cure a patient. Instead, we have them examine the patient and come up with their own diagnosis, and we help their thinking by asking questions. "It’s a very similar process to the one we use to train lean practitioners – asking questions, not feeding answers. We actually find analogies in many industries. Doctors have a standard workup for patients, nurses have a nursing assessment, lawyers have legal briefs, pharmacists have medication assessments… and lean practitioners have their A3s," he explained.
When I asked him to reflect on the state of healthcare industry, Jack’s tone changed slightly. "There are so many problems in healthcare, and processes tend to be so messy. It’s a miracle patients get through it," he told me, before moving on to a more positive note. "Healthcare is a good example of the quote from Fujio Cho, 'Brilliant people, broken processes, mediocre results'. Most patients make it through the process pretty well, thanks to the brilliance and compassion of the people solving local problems and making the imperfect process work, often against all odds. Imagine what they could accomplish in a brilliant process they designed!"
To him, the most satisfying part of lean thinking is seeing the pride people have in their experiments, in the iterations they went through, and in the colleagues they engaged while trying to find out more about a problem. "When I see that, I am hopeful, because the enthusiasm one has for improving things is much more important than any single problem our organizations might face," he concluded.
Dr Jack Billi is Chief Engineer for the Michigan Quality System, University of Michigan Health System. He serves as Professor of Internal Medicine and Medical Education at the University of Michigan Medical School, and as Associate Vice President for Medical Affairs of the University of Michigan. He leads the Michigan Quality System, the University of Michigan Health System's lean transformation strategy. Dr Billi's research and management interests include the use of lean thinking to improve quality, safety and efficiency in healthcare, evidence-based guidelines, population health, clinical practice transformation tied to performance-based differential reimbursement, and conflict of interest management.