There are my top 10 lessons learned from practicing the Toyota Kata approach in a healthcare setting.

1. MY TOP 10 LESSONS LEARNED
FROM PRACTICING THE
TOYOTA KATA APPROACH
By Michael Lombard
March 2014

2. Background…
The topic here is lessons I've learned
(so far) from my grassroots effort to
infuse the Toyota Kata methodology
into the culture of an acute care
hospital in the Dallas-Ft. Worth
metroplex.
When we began testing the Toyota
Kata approach we had no experience
with or knowledge of it at all, outside
of having read the book a few
times. We had no budget to bring in
experts or send ourselves off for
formal training.
Context at a Glance
•
•
•
•
Acute care hospital in the
Dallas-Ft. Worth metroplex
No prior Toyota Kata
experience or expertise
No budget for consultants or
off-site training
Strong leadership support
for continuous improvement
But, thankfully, we did have senior leader support to
try something different; they were ready to invest
significant effort in building a sustainable culture of
continuous improvement at our hospital.

3. How we started…
We didn't know where the path would take us, but we took a
step forward anyway. First, we selected an Advance Team from
different departments and levels of the organization. Then, we
did a tiny bit of home-grown training and quickly got to work
practicing the Kata in the real-world.
Advance Team
Selected
Initial Training
Practice &
Learning
Sharing Lessons
Learned
June-July
2013
August-Sept
2013
Sept 2013-Feb 2014
(& Beyond)
March
2014
Now, after about six months of real-world application
including several hundred coaching cycles, I have some
lessons learned that I'd like to share...

4. #10
A PDSA cycle is not what
I thought it was…
I always thought a PDSA cycle was when
you had identified a countermeasure to a
problem and wanted to test it. Well, yes,
that is one type of PDSA cycle, but there's
more than one kind.
Sometimes, our PDSA cycle consists of
nothing more than a quick "go & see" to
confirm or deny a hypothesis, without
changing or implementing anything at all.
I've come to see a PDSA cycle as simply
the act of taking a step forward with the
intent of learning something in the
pursuit of improvement.
3 Examples of PDSA Cycles
1. Go and See: Direct
observation and data
collection, without changing
anything, to learn more
about a process or situation.
2. Exploratory Experiment:
Introducing a change in a
process to see, via direct
observation, how the
process reacts.
3. Testing a Hypothesis:
Introducing a change, ideally
in only a single factor,
together with a prediction
of what you expect to
happen.

5. #9
Cues, routines, and rewards
matter…
Since organizations have many built-in impediments to
organic continuous improvement (annual performance
reviews, TPS reports, etc.), we must actively pursue
continuous improvement through organizational habitbuilding.
In The Power of Habit, Charles Duhigg explains that for
new habits to form, we must have a habit-building loop
in place consisting of a cue, routine, and reward.

6. Cues
• Formal coaching cycles
• Visual signals (e.g. 5
Questions pocket card)
Toyota Kata
Habit-Building Loop
The Toyota Kata approach provides all 3
elements of habit-building in abundance
Intrinsic Rewards
Routines
• Learning
• Solving problems
• Attaining Kata mastery
• Improvement Kata
• Coaching Kata

7. #8
Track the metrics
of habit-building…
A target condition should always be measureable.
However, in the early stages of Kata adoption the focus
is more on building habits than producing huge process
improvements
with
eye-catching
ROI
calculations. Therefore, it's advisable to also have a
way to measure progress in terms of habit-building.
For example, we can track the # of Kata "practitioners",
# of Kata coaches, # of PDSA cycles performed, etc. I'll
admit that this is a highly imperfect set of habit-building
metrics, so I'm hoping as a community we can come up
with something better.
One option might be to measure what level of skill our
people have attained using a standardized rubric, as
suggested in some of Mike Rother's online material.

8. # Improvement Kata Practitioners by
Month
45
40
35
30
25
20
15
10
5
0
# Coaching Kata Practitioners by
Month
14
12
10
8
6
4
2
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
0
Jul-13
# PDSA Practitioners Added
Aug-13
Sep-13
# PDSA Coaches Added
Cumulative Total # of PDSA Practitioners
# PDSA Cycles Performed by Month
Oct-13
Nov-13
Dec-13
Jan-14
Cumulative Total # of PDSA Coaches
# Departments Utilizing the Kata by
Month
250
25
200
20
150
15
100
10
50
5
0
0
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
# PDSA Cycles Performed
# Departments Added
Cumulative Total # of PDSA Cycles Performed
Cumulative Total # of Departments Using PDSA
Jan-14

9. #7
Clinicians and other front-line
staff tend to like the Kata
approach.
Target Condition
I think this is because it allows
them the freedom to take one
bite of the apple at a time. They
are free to try a small change or
just go get more information, all
in the pursuit of learning and
iteration. This reduces the fear of
failure and the stress of trying to
do too much all at once.
It's quite liberating to be able to
see the top of the staircase and
take a single step at a time.
Current Condition

10. #6
It works on big projects too.
We've seen great success in using the four steps of the
Improvement Kata as a roadmap for fairly large improvement
projects; the 4 routines of the Improvement Kata serve as
project phases, as shown below…
We utilized a Steering Team to build
consensus for a vision statement, KPIs, 1-2
year goals, etc.
The cross-departmental team developed the
future-state map and built consensus with
the Steering Team to obtain approval.
IK STEP 1:
IK STEP 2:
IK STEP 3:
IK STEP 4:
• Understand the
Direction
• Sept-Oct 2013
• Grasp the Current
Condition
• Oct –Dec 2013
• Establish the Next
Target Condition
• Dec-Jan 2014
• PDSA Toward the
Target Condition
• Jan-April 2014
We utilized a cross-departmental team to
analyze the current-state via a series of halfday “work-out” sessions.
We broke up the future-state map into 6
elements that were assigned to 6 learners
who were guided by 1 coach.

11. The Improvement Kata can be utilized
for any type of improvement
effort, including big, formal
projects. The four routines of the IK
provide a nice 4-phase framework upon
which we can plug & play whatever
project we need.
IK STEP 1:
IK STEP 2:
IK STEP 3:
IK STEP 4:
• Understand the
Direction
• Grasp the
Current
Condition
• Establish the
Next Target
Condition
• PDSA Toward
the Target
Condition

12. #5
Target Conditions ≠
Numerical Targets ≠
List of Countermeasures
This was one of the hardest things for me to grasp as a
coach. I almost immediately understood that a target
condition is not the same as setting a numerical target or
goal; yes, we actually have to describe the future mode of
operation that will produce the results we seek. This I
understood.
What I didn't understand was that describing the future
mode of operation does not require us to know exactly how
we will achieve it. In other words, we don't need a specific
list of countermeasures to be able to describe the target
condition. In fact, it's better not to lock ourselves into preconceived notions of what solutions are needed before we've
began testing via PDSA.

13. Here’s a comparison of numerical targets vs. countermeasures
vs. target conditions using a healthcare example…
Scenario
Numerical
Target
We
want to
improve
patient
safety
10% reduction
in medication
errors by Q2
2014
Countermeasures
• Implement
CareFusion barcode
scanning
• Switch to new
armbands that don’t
wash out
• Re-train nurses
We often think that setting
measurable stretch targets
will motivate our people to fix
the problem, but that’s based
on an assumption that a lack
of accountability is the root
cause of the issue. Where’s
the evidence for that?
Target Condition
A future-state of a highly
reliable armband scanning
process powered by
automation that will reduce
the risk of missed armband
scans to reduce medication
errors by 10% within 30 days.
Too specific. Preselecting the specific
means by which we’ll
achieve the target
condition assumes we
know what will work
prior to testing.
Where’s the evidence?
More specific than a
vision or True
North, but not so
specific that we’re
left no room to
iterate based on
what we learn
through testing.

14. #4
Root cause analysis is
an iterative process.
I always thought of root cause analysis as a routine we
performed
prior
to
identifying
potential
countermeasures. We'd use 5-Why? or whatever to identify a
root cause, then come up with countermeasures to address
it. What I learned through the Kata approach is that we don't
have to fully understand the root causes of a problem before
we can start testing countermeasures. In fact, the act of testing
countermeasures (via PDSA) is in and of itself a fantastic way to
identify root causes in an iterative and scientific manner.
In other words, PDSA is an empirical approach to root cause
analysis, that can be utilized alongside statistical and practical
techniques…

15. Find the right mix of statistical, practical, and empirical root
cause analysis techniques to keep the “batch size” of your RCA
work at an appropriate level to reduce the risk of errors in
your analysis…
Statistical
Techniques
• Regression
• ANOVA
Practical
Techniques
• 5-Why
• Ishikawa Diagrams
Empirical
Techniques
• PDSA Testing
• Design of Experiments (DOE)

16. #3
Coaching is tricky.
Even though the Coaching Kata
provides clear instructions on
what questions to ask (the 5
Questions), novice coaches
typically struggle with how to
stick to the script without being
too robotic and awkward about
it. It's a balancing act. A Coach
must be able to sense when the
Learner is in need of strict
structure (new learners often go
off in ten directions at once and
need to focus on the single next
step) and when a more
creative, free-flowing discussion
is appropriate.
Practical Coaching Tips
1. Don’t kick-off a coaching cycle w/
the 5 Questions: break the ice first
to make the Learner comfortable.
2. Utilize visuals: always have the 5
Questions pocket card, 5 Routines
placemat, etc. on-hand as teaching
tools and visual cues for routines.
3. Expect awkwardness: it’s okay to
admit that following a “script” can be
awkward at first. Get it out in the
open early in your engagement.
4. Go off-script: it’s fine to meander
during a coaching cycle in order to
introduce a new tool just-in-time or
to tell a story to spark the creativity
of the Learner.

17. #2
Coaching means providing
a safe environment to fail.
“I have not failed. I've just found 10,000 ways
that won't work.” ― Thomas Edison
Mastering the Kata is mostly a learning-by-doing effort
that relies heavily upon repetition and deliberate
practice. The Coach should foster an environment that
allows the Learner to practice and fail (and trust me, in
the early going most of the practice results in
failure). Because 'practice' in this context occurs in the
real-world (not in some classroom simulation), these
failures must also be done in a safe manner that causes
no irreparable harm or embarrassment.
The Learner’s target condition has an achieve-by
date, and that target condition is where the benefit
comes from. Don’t fall into the trap of thinking that
each step along the way should provide a benefit!

18. #1
When in doubt, take a step
forward and reflect!
Fortune favors the bold.
How to get started?
1. Get a group of leaders passionate about continuous
improvement and get them to read and discuss Toyota
Kata with you.
2. Form an Advance Team of folks from different
departments and levels of the organization and have
them shepherd the overall deployment.
3. Find a sensei, someone who can “coach the coach” to
help you get started.
4. Train up the Advance Team as best as you can and start
practicing the Kata routines (prepare to make mistakes!)
5. Once you reach that target condition, you’ll know what
to do next!

19. About the Author
Michael Lombard is a seasoned leader in healthcare performance
improvement. His mission is to help healthcare systems deliver
ever-increasing value to patients and the community by improving
quality and reducing cost. His approach is to get results by
facilitating process improvement while increasing the improvement
capabilities of the people in our organizations, in an effort to build
cultures of continuous improvement.
His goal for writing is to explore ideas and continuously improve his
understanding of kaizen in healthcare settings.
Please feel free to contact Michael…
@MikeLombard
LinkedIn
mlombardjr@gmail.com