The Mölnlycke O.R. blog
Healthcare and the legacy of the 1920s car industry, part 3
Dr Magnus Lord is one of Europe’s leading experts in modern healthcare management, including Lean healthcare. He holds three university degrees - medical doctor, master of science and a bachelor of business administration degree. A former strategy director of one of Sweden’s largest university hospitals, Lord is now working as an international lecturer and coach for executive management groups, helping them to lead their transformations.
In the first two instalments of this series (Part 1 and Part 2), I described the present, obsolete production system in healthcare and showed the first principle of the new philosophy – the Principle of Flow. In this final part I will describe the second principle – the Self-Improving System.
The Self-Improving System is based on the fact that employees, not leaders, are best suited to solve the problems of our processes. Why? Simply because employees have the best knowledge of the situation. The leaders’ task is to develop employees’ capability to do this. How this can be done will be described in this article.
It all comes down to continuous learning – learning what is real value for the patients, what makes a good or a bad day, what affects the outcome of a procedure, how to discover deviations and so on. That is why we need to start with studying the art of learning.
All practical learning is based on two things – a plan and the follow-up on that plan (i.e. whether we got the result we expected). In a scientific experiment we start with a hypothesis, perform the experiment and check whether the hypothesis was correct. It is interesting to note that the quantum leaps in science are normally achieved when we do not get the result(s) we expected.
Sometimes the plan seems simple – we want to hit a golf ball 250 yards straight. But to achieve such excellence we must break down the plan into hundreds of sub-plans and sub-goals. The best angle of the elbow, the weight distribution of the feet, the speed of the back swing, the exact distance to the ball, etc. The learning (understanding) occurs when we do not get the desired result – the analysis of what went wrong and why.
The Self-Improving System is based on the same reflective cycle. We need to define what we want to achieve in every part of the operation and follow-up to find deviations, to increase our knowledge about what affects the outcome.
It is important not to place value judgments on the deviations. They are neither negative nor positive – they just exist. We want to look at the deviations with a scientist’s surprised and curious mind; to analyze the root causes of them and try to eliminate them, making sure the problem does not occur again (or at least not as often).
This improvement cycle is well-known: PLAN – DO – CHECK – ANALYZE – IMPROVE. Every revolution is a complete learning cycle. The best organizations in the world do not, however, regard the cycle as a static definition of learning; they make sure the system is an active improvement engine. The secret lies in establishing two structures for this and incorporating them into everyone’s work day.
The first structure covers the first three parts: PLAN – DO – CHECK. It normally consists of a “Daily Control Meeting” or “Pulse Meeting”. The team and their leader gather for a couple of minutes, normally once a day. They start looking back, checking whether yesterday’s results were according to plan or if they had any deviations. The more and smaller the better – the aim is to discover problems while they are still “buds”. The team writes down the deviations or defects (or good ideas) on post-its and goes on to look forward. What is the current state of our process? Are we in-control or out-of-control (for instance having more than our max limit, 12 patients, waiting)? Do we have to make any alterations to our plan today?
The daily meeting has two purposes: to find deviations while they are still fresh, and to make a realistic plan for today, based on the current situation. The more detailed the plan, the more and better the deviations.
Example: We have agreed on a standard process for how to handle a patient visiting for an annual blood pressure check-up. When the patient arrives at the consultant, she discovers that one test, planned to be taken earlier by the nurses, had not been done. The doctor writes down this deviation on a post-it and brings it to the next day’s Pulse Meeting, where it is placed in the in-basket of the Improvement Board.
It is once again important to underline that the note is neither an accusation nor blame. If a nurse has forgotten the test, we ask ourselves how we can make it easier to remember. We are human beings and we tend to forget things. If she misunderstood the standard process, we try to make it clearer. If she lacked relevant training, we improve the training system. We work with processes, not blame or reprimands.
The second structure is the Improvement Meeting, where all the deviations end up. It is normally held weekly and is a short meeting where new deviations are prioritized; ongoing improvement activities are followed up and new ones started. All employees should be involved in one improvement activity each. The improvement work itself – analysis, development of standards, tests and so on – is not done during the meeting. The purpose of the meeting is just to support continuous improvement progress.
One important difference compared to the old system is the size of the improvement activities. They are not large improvement projects. We expect the vast majority of them to be finished in less than an hour. We try to solve many small problems.
To aid this work we need a third structure – visual control. All relevant facts and the current state of the processes must be visual to make sure everyone can make the necessary decisions just in time. Normally boards are used, and the meetings take place standing in front of them.
The managers’ task is to create these structures, participate themselves, train the employees and if necessary take care of a problem and escalate it upwards until it has reached the level where it can be solved. The continuous, daily escalation system is the fourth structure, which forms a necessary vertical flow in the organization.
The managers of a modern organization, though, have to do more than simply implement these four structures. To be able to build employees’ capabilities they have to change their own behaviour. What the leaders do makes the difference; not what they say. They need to be coaching, listening, supporting, fact-based and present at the workplace most of the time, understanding the real problems occurring in the daily work environment.
The managers’ behaviours are really nothing but processes, so they must apply the same structures for improving them as the employees do. It includes standardizing some of the leadership work to make possible high, even quality, and finding deviations for further learning. To make this possible, they need to visualize both plans and outcomes. Examples of leadership standard work could be: presence in gemba (the workplace) two hours daily, coaching one team leader after her Pulse Meeting daily or interviewing one patient weekly. Any deviation, when a leader is not able to do her daily coaching for instance, is analyzed and improved.
The future hospital is not so hard to imagine. Specialists and departments work together around the patients to make them flow through the hospital without unnecessary waiting, and deliver the best possible value to the patient. Everything is planned beforehand to be able to detect deviations, to augment continuous improvement. Both the plan and the outcome are visualized in a simple way to support learning and decision-making. The aim is to discover problems while they are still small, and feed them directly into the improvement system. The hospital is entirely blame-and-shame free. The improvement work is done by the employees and the benefits of their improvements are shared in an ethical way between themselves, the patients and the taxpayers. The managers constitute a real-time support system to make this work. Their main task is to build the employees capabilities to improve every process every day.