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4DX and Lean
4DX and Lean

As I coach executives in health care systems around the country, I’m hearing interest in 4DX and Lean. I’ve seen hospitals implement both, and spurred by the recent interest, I reread The 4 Disciplines of Execution by Sean Covey, Chris McChesney, and Jim Huling. It’s well written and compelling in the stories they share of success realized by companies who have adopted this approach to management.

Comparing 4DX and Lean I see similarities, and important significant differences. To begin, let’s review the key concepts of the 4 disciplines:

The Four Disciplines

Discipline #1 – Focus on the Wildly Important. Focus is key to excellence. As I tell my kids, “You can do anything you want, you just can’t do everything you want.” When an organization tries to pursue more than a very few goals, it’s impossible to excel. You can’t be the best at everything. This focus is a challenge for every organization, AND even more so for health care, as we face ever growing demands for better quality, safety, service, and financial performance. Every regulator and payer wants to ensure providers are doing the right thing for their patients, and many have varying opinions on what measures are important and what the target should be. The 4DX authors explain that front line workers are just trying to survive the “whirlwind” of demands and activities we face each day. Trying to significantly improve performance on more than one or two specific goals is impossible. They name these few goals “Wildly Important Goals” or “WIGs” for short.

Discipline #2 – Act on the Lead Measures. Senior leaders focus on “lag measures” – the outcomes that are reported monthly or quarterly and tell you how you did. They are, of necessity, outcome measures. These are important for many reasons, but they don’t provide the real time information you need to do to improve performance. Lead measures do this. They are the more granular measures that drive the lag measure performance. Lead measures may be outcome or process oriented. If the goal is to improve access as measured by the 3rd next available (3NA) appointment (a lag measure), the lead measure would be the number of open slots in the schedule at the start of each day. The more open slots, the more likely that the 3NA measure will improve and the goal will be achieved.

Discipline #3 – Keep a Compelling Scorecard. You can’t tell if you are achieving your goal if you don’t keep score. You don’t know the score without a scorecard. A compelling scorecard drives employee engagement in the improvement process. A compelling scorecard: 1) is visual so all the team members can look at it together during meetings, 2) is designed by the team members so they feel ownership, and 3) is designed so that anyone can quickly assess the progress of the team toward achieving the goal. The scorecard is populated with the one or two key lead measures that will drive success for the team.

Discipline #4 – Create a Cadence of Accountability. Accountability is key to success. The 4DX process focuses on the accountability of each individual on a team to keep their commitments to improve performance on the lead measures. The team meets briefly weekly (up to daily depending on the team) during which time each team member reports out what their commitment was from the prior week and how they did on meeting that commitment. Successes are celebrated. Failure to keep the commitment is addressed, usually by the team member agreeing to work harder to make up for the missed commitment and achieve the new commitment for the coming week.

How do 4DX and Lean Compare?

4DX and Lean have a number of similarities, and a number of differences. First the similarities:

  • Focus on the Wildly Important – Both Lean, through Strategy Deployment, and 4DX, through WIGs, make focusing on a limited number of goals a priority. This is key to success as discussed above.
  • Act on the Lead Measures – Both 4DX and Lean identify the measures that drive success in achieving the organization’s target goals, and focus on these. Both engage the front line workers in choosing the goals, which is key to employee engagement.
  • Keep a Compelling Scorecard – Both 4DX and Lean use visual management to engage the front line workers in improvement efforts. Few other management approaches use visual management to the degree that 4DX and Lean do.
  • Create a Cadence of Accountability – Both 4DX and Lean have regular brief meetings as a key component of the management system. In Lean, the huddle is usually daily. In 4DX, the standard is a weekly brief meeting, although some organizations find a daily huddle more helpful.

So what are the differences between 4DX and Lean? As I see it they include:

  • Identification of Priorities – 4DX recommends involvement of key leaders in a brainstorming session to identify important issues and then choose priorities. Lean uses the A3 process for root cause analysis to ensure effective lag and lead metrics.
  • Participation of Senior Leader – 4DX is focused at the front line and the workers’ immediate supervisor. This is important because it is where the actual work is being done and value is being added. Lean adds a priority for senior leaders to become actively involved, going to the gemba to coach huddles and observe the work as it is actually done. As a result, the leaders have a much deeper understanding of the challenges the front line workers face, and the workers know that their leaders care.
  • Individual Accountability and Focus on the Person Versus the Process – 4DX focuses on holding the individual worker accountable for keeping their commitments to the team. This is important. Lean adds a focus on ensuring that the process the workers follow is the correct process. This focus on the process, rather than the person, reflects a deeper level of the key Lean principle of “Respect for People.”
  • Problem Solving – 4DX encourages problem solving, but does not focus on this as strongly as Lean does. In Lean, when problems are identified with the process, the team analyzes the process to understand the root cause and then designs experiments to address the root cause and fix the problem.
  • Personal Development – 4DX requires managers to work differently than they did before 4DX – such as a holding daily or weekly meeting and using visual management boards. Lean requires managers to do this, as well as to focus on root cause and develop their teams to solve problems, rather than focus on individual accountability of their workers. Developing managers as coaches and mentors is a greater challenge.
  • Accepting “the Whirlwind” as the Status Quo – 4DX focuses on WIGs for good reason. In most jobs there is a whirlwind of activity and demands that consume our days and keep us from achieving our goals. Ensuring focus on our goals enables successful accomplishment in spite of the whirlwind. 4DX accepts the whirlwind, rather than acting to reduce its impact. Lean works to reduce the whirlwind through Value Stream Improvement, focusing on removing waste from workflows and stabilizing the work environment. This is not easy. While each pass through a value stream reduces the whirlwind, it often takes 4 or 5 passes through a value stream to achieve the level of transformation in which the whirlwind is the exception rather than the rule. When a team achieves this, it is truly transformative, resulting in performance that is nearly impossible for competitors to match.

What is the Right Choice for Your Organization?

4DX is easier to implement than Lean. It seems “faster”. It can be taught to a large group of managers with a modicum of effort and time commitment. Managers with a talent for motivating others will do well with it. It can drive significant improvement in performance. It is harder to maintain in the long run.

Just like Lean, I’ve seen it fail. And when it is successful, it does not drive true transformation. 4DX accepts the “whirlwind” rather than committing to ending it. It focuses on holding people accountable, but does not commit to developing people and teams as problem solvers.

As someone who has led a successful Lean transformation, which truly transformed our medical group to the highest overall rating of 170 medical groups in California (Sutter Gould Medical Foundation, 2014 and 2015 Consumer Reports), my recommendation is to invest in Lean. To succeed, you need to invest time and money. You’ll also have to invest in Lean consultants to help you started.

The Most Important Investment

However, the most important investment is the investment of top leadership’s time in going to the gemba, participating in improvement work, and learning to be Lean leaders. If you don’t make this personal investment, it doesn’t matter which approach you choose. You will not realize the return on investment you need to thrive in the ever changing world of health care.

What do you think?

Have you experienced 4DX or Lean in your organization?

What would you recommend to others?

Please share your thoughts in the comments.

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