With Lean back in the news, and taking center stage during the election,  I think it's time we talked about it. For me, the most disheartening part of the political discourse is the taking and defending of entrenched positions. Where we need nuance and subtlety, we get knee-jerk responses designed to provoke reaction rather than invite curiosity. Perhaps we can emerge from our corners to take a look at Lean with some hopefully useful rather than reactionary critiques.

Lean, in the classic sense, is mostly about waste and it's very popular today to discuss waste in the context of healthcare improvement. Much of the time, we are discussing the classic wastes identified by Taiichi Ohno of Toyota: transportation, inventory, motion, waiting, overprocessing, overproduction, and defects or errors. Or, if we don't like the Lean approach taken in Saskatchewan, we talk about the waste of money in hiring consultants and traveling out to see what other industries do and the "ridiculous" notion that something from car manufacturing could apply in healthcare - which kind of misses the point for me. There is much to critique about the path we've taken, but not this. Healthcare is rife with opportunities to identify and drive out these classic forms of waste and we are fools if we think we can't learn from other industries or outside perspectives.

So what would I challenge? At least 3 things:

1) Despite all the talk to the contrary, we've taken a very mechanistic "Lean as tools" approach. If you actually take the time to understand what Toyota did, you will realize that it is a management approach more than a set of tools that made the difference. People avoid the management side, it's messy and uncomfortable and challenges those in positions of power to change just about everything they do. Mark Graban has created a fantastic Storify that summarizes some key Deming insights into leadership. My personal favorite: "Management by walking around is hardly effective either. The reason is that someone in management, walking around, has little idea about what questions to ask, and usually does not pause long enough at any spot to get the right answer" - turns out "going to gemba" isn't so simple after all. 

2) We overestimate Lean's applicability in healthcare. We are not very sophisticated in our understanding of how and why Lean works in healthcare and where and why it might struggle. For me, Lean works nearly perfectly to address areas of service and care with high throughput, highly repetitive tasks, and low involvement or engagement of the patient, client, or family. Think the lab, materials management, admission, surgical processes like room turnover, imaging...for me these are the places to take a Lean approach with some confidence. 

But what happens when we try and apply these methods in situations where processes are more subtle and involvement or engagement of the person receiving the service is high? This classic diagram from ASQ highlights the issue.

In much of healthcare, the customer and what is being transformed in that middle section are one in the same. This has some serious implications and is a very special situation compared to other service industries, never mind manufacturing. I could be wrong, but I think healthcare, social care, and education are unique in this matter. We also tend to totally ignore the need for processes to be adaptable (point #3 under process evaluation in the diagram above) - in the focus on reliability, we miss that resilience is often more appropriate in complex systems. 

3) We tinker at the margins by avoiding what I will call the wicked wastes. Similar to Zimmerman's wicked questions which are used to expose the assumptions we hold about an issue or situation in Complex Adaptive Systems work, wicked wastes surface potentially challenging differences in our mental models. Wicked wastes can't be designed out without some seriously hard work aka long and difficult conversations.

This is a work in progress, provoked by Paul Batalden, and likely incomplete, but let's consider some potentially wicked wastes:

• power structures - that's right, the good old hierarchy. The deeply embedded mental model that preserves the concept of the "physician's lounge", maintains processes designed to keep patients and families out of the loop (pay to access your chart, no family in the OR or procedure room), and generally impedes good communication within and across professions and groups involved in delivering health care.
• cherished myths -  "care happens in the interaction between a single provider and a patient", "the doctor knows best",  "patients and families don't want to be involved in decision making", "if we just try harder, things will improve", "if we just add people, space, resources, time - our quality issues will vanish", "there is one right way to improve"...take your pick
• an inability to shift our focus upstream - there is an underlying assumption that the structure is right, it just needs it to be faster and more reliable. We continue to pour enormous resources into optimizing the acute care system and ignoring the primary, public, and preventive care system.
• persistently siloed thinking - organizationally, professionally, but also in improvement methods, we seem unable to get our heads around true integration. 
• business models that constrain value-based design - direct from Batalden, this one is a zinger...is it possible that the granddaddy of waste reduction might actually generate waste if applied inappropriately? You better believe it.
• avoidance of key discussions regarding values conflicts - professional advocacy that clashes with improvement or true patient-centered care for that matter. The tension between espoused organizational values (safety, patient-centered care, collaboration) and observed organizational values (productivity).
• overuse -  not overproduction which presumes that you are doing more than enough of a right thing but the waste of doing the wrong thing altogether.

I would suggest we approach our very complex challenges in this very complex system with some humility and be willing to bring to bear all the approaches, tools, and strategies that could help - this means being eclectic and pragmatic. And courageous. And curious. I promise it won't be a waste of our time if we try.

As the year begins, I am recommitting to my blog, to sharing the last two years of experiences and insights, as well as anything new that comes along, both as a means for self-reflection and to also provide some hopefully unique and helpful insight for those of us trying to make the system better. Stay tuned :-)

There we were, Hilda and I, awaiting admission in the ER after her diagnosis. The wait was 44 hours. One might think this was an unusually busy time or strange week; but we had to come in again, 2 weeks later, after complications from chemo sent us back in an ambulance. The second time, the wait was 48 hours. I'm not exaggerating.  

And it wasn't because they didn’t realize how sick Hilda was or were only thinking to admit to oncology, nope - they were pretty much trying to find a bed anywhere. Hilda eventually ended up on neurology for a few days and was then transferred to oncology.

Our experience is not unique. If you live in Saskatchewan and pay attention to the news, you might have noticed quite a lot of press about too many people being in the hospital. There are people in acute care beds waiting for placement in long term care and people in emergency waiting for acute care beds and a lot of stress and pressure in the middle.

The good part about this situation is that there has been a renewed interest in long term care itself, the need for good community services and home care, and better support for families who are able and wanting to care for family at home. And it’s high time, because, while all the smartest people say the key to transforming the healthcare system is focusing upstream, on health promotion and disease prevention – and I don't disagree – we are missing the boat unless we start focusing simultaneously downstream.

So maybe it all seems obvious – problem and solution – but I want to challenge us to consider that one of the contributing causes might actually be our improvement work. That's right, the ever-present “unintended consequence” provoked when making changes in complex systems like health care.

I applaud the scope of the provincial Lean approach, which focuses on safety, surgical care, primary care, and even those folks needing placement in long-term care - you can read more about it here. But I have some concerns.

See I think acute care is technically midstream and we are hip deep in trying to improve flow by improving efficiency of acute care processes, like surgery and emergency care. We are stuck midstream. 

It's so tempting to start with acute care, what with all the people being co-located in one space, the bulk of the services clearly within the purview of health rather than social care, and the volumes. Oh the volumes! It's also the most obvious pain point - all the upstream and downstream issues seem to become visible midstream.

I have some suspicions about why it's a problem to improve the middle first. In essence, I worry about the lack of attention to two apparent paradoxes, the need to work backwards and the need for sub-optimization.

1) Work Backwards

When teaching about improvement in the past, I have always guided teams to look at pressing need or "quick wins" as indicators of where to start. However, I have a growing sense that there is "right" order to improvement, at least when focused on efficiency or increasing productivity, and that it's back to front. Ramp up surgical volumes before improving the downstream piece and you end up with a whole lot of people in acute care beds waiting to be discharged post-total joint or fracture or what have you. Maybe the system can generally handle all the folks waiting for long-term care placement. But add the folks who are in for “sooner, safer, smarter surgery” and experiencing a whole lot of efficiency improvement and you head towards unintentional disaster. While less obvious, it might be better to start downstream, open up and optimize capacity in the community and long-term care, so that when you start to increase volumes through acute care, there is somewhere for the people to go.

2) Sub-optimization

Complex systems are, as the name suggests, complex and treating them as simple will not make them so. As a result of being complex, they are very sensitive to things like unintended consequences. They are also full of paradoxes. Improving the larger system is not as straight forward as making all the parts of the system work optimally. You have to pay attention to the interactions and connections between all the parts too. Like a sports team that fails when one player optimizes at the expense of the rest of the team (think the classic ball hog), the health system needs to sub-optimize the parts to make the whole optimal. If we optimize surgical processes, it can create strain on all of the other processes leading in and out of surgery and those nearby too. Are we watching and ready for the strain?

So there you have it, my opinion (take it for what it’s worth) on one reason why there are so many people waiting. 

Of course, these ideas are more like inklings on my part, not necessarily well-informed or well-formed. What do you think?

Is there a right order to process improvement (especially when focused on efficiency)? Is it better to work backwards?

Are we being attentive enough to unintended consequences of our own improvement success?

Does the principle of sub-optimization make sense and have you seen it at work before?

p.s. I am very sad to say that Hilda, my lovely mother-in-law, never made it home after her second admission. Despite the best efforts of those who cared for her, she died on August 30. You can read more about her life here.

Ninety-nine percent of the people in the system are exceptional. Sure, a small number of people have clearly chosen the wrong field or need a break, but the real disappointment is the system itself - the lack of systems really. I will post soon on specific issues that we have and continue to experience, but today I want to honour some of the 99% (in order of appearance, not importance).

To Floyd, MD - when you arrived in the ER exam room, you introduced yourself in this way, "Hello, I'm Floyd, your resident physician - I'm going to take care of you tonight". And in this humble but competent way, with no title to create distance, you did care for Hilda. When you entered the room and saw she was crying, you didn't avoid an uncomfortable discussion but asked what was causing her to cry. She told you she was thinking about her family (she knew something major was wrong) and told you about her sons and their wives, her husband, and her special dog. You didn't brush this off, but asked more details and then moved into the clinical reason you came back into the room. In total, I think this interaction took 2 minutes. We will never ever forget it.

To Kevin, MD  - you hardly knew us when you had to break the news that Hilda had cancer, likely ovarian. You were kind and compassionate in delivering very hard news. Thank you for being honest and kind.

To Tammy, LPN - you started your shift by introducing yourself with clarity and humour, "I'm Tammy, Yan (the RN) is the boss, but I'm the bossy one!". You noticed Hilda's Stuart McLean book on her bedside table and used this common interest to anchor a connection. You came in early for your shift to talk to Hilda and shared personal stories about your life and your family in a way that made Hilda feel much less alone.

To Elena, MD - from the moment Hilda met you, she loved you. You sat with her for 20 minutes and gave her the straight goods about ovarian cancer treatment. You don't mind my endless lists of questions and you always answer honestly, but with compassion and hope. As you said, in your business, you can't deal in platitudes, but you do deal in hugs. I've never asked a doctor I didn't know well to hug me - truth be told, not sure I have ever asked a doctor to hug me. But I felt compelled to ask you the other day and when you did hug me, it was real - a maximum dose of human compassion that increased my confidence in your medical skills

To Doreen, housekeeping - on the day after Hilda was transferred to City Hospital, you stopped my husband in the hall and asked how she was doing. Another morning, you showed up fairly early to clean Hilda's room and explained that you noticed how early her family came to visit so thought it would be nice to clean her room first. You came to say goodbye when she was transferring to Royal University Hospital, stopping to chat and share your own battle with cancer. You hugged her and promised to stay in touch. Thank-you for understanding how to create value for patients and families in your work. You demonstrate how housekeeping staff play a vital role in caring for people.

To Laura, RN - when we arrived on the oncology ward at RUH, we were all overwhelmed and scared and it was so busy and felt crowded compared to City Hospital. When you showed up, one of Hilda's longtime customers and friends, you lit up the room by lifting Hilda's spirits. Thank you for honouring your friendship by providing caring service to Hilda, even though she wasn't technically "your" patient.

To Holly, RN - my husband and I think you are the perfect balance of competence and compassion. I never felt worried that you wouldn't do the right thing. When you weren't sure about something, your ego wasn't an issue and you asked for help. You believed us when we explained that Hilda's veins just weren't cooperating and needed an anesthesiologist's touch. But you also were so genuinely kind and caring and we so appreciate it.

To Joanne, EMT - when you came to transfer Hilda on her second admission, you were so clearly aware of our fragile situation and you advocated for us. You took charge of the transfer situation by teaming up with me and I so appreciated your respect and collegiality before knowing what I do for a living. When we were holding in the RUH emerg hallway, you kept on top of the bed situation and took it upon yourself to clean the room that came available so that Hilda could have some privacy in a very hard situation. That seems like a lot, but then you also remembered us and took some time the next day when you were back in RUH emerg to come and see how we were doing and express your regret that we were approaching a god-awful number of hours waiting for an inpatient bed. Thank you for remembering.

There are many more, Yan and Donna and Shirley and Vivian and Alfeo and Danny and Marichu and Jeff and Brian and Joel and Anita and more and more every day. What is key, as I read back over these experiences, are the exceptional moments when people transcend their professional roles. When they bring all that they are - their interests and passions, their compassion and humour, their challenges and struggles - to be fully present in the caring experience. This, to me, is the key value in our often flawed and ailing system - I hope we don't mistake it for waste or create systems of care that impede the flow of such powerful human connections, but more on that next time...

- Archibald (1997) 

When delivering workshops on system improvement, the number one question that gets asked is some variation of “how do we get others on board with our change initiatives?” Sometimes it’s framed as convincing, sometimes engaging, and often as overcoming resistance.

This is a key challenge facing those wanting to lead improvement in their organizations and I always get the sense that people want the “five easy steps to engaging others” checklist. So, here’s the bad news, not only are there not five easy steps, I don’t believe there is any way around the tough slog that involves: intentional and authentic listening - including tough conversations - and deep self-reflection.

Intentional and Authentic Listening – instead of talking people into change, try to listen them into change. You can listen in subtle ways, by paying attention to signals around you, or in more explicit ways, by engaging in ‘tough’ conversations. The toughest part about the necessary conversations can be finding the time to have them. Once time is made, you need to stay open - watching your facial expressions, body language, and words – and try and maintain a state of curiosity about why the idea you have fallen in love with, might be threatening or distressing to others.

When people feel truly heard, when their concerns result in adaptation of an idea or how it is tested, you may be surprised to find that resistance is transformed into energy for change. Resistance is a signal to you that the idea you propose could actually have some impact. If you come up with an idea for change that provokes no ‘resistance’, I would challenge you to come up with something more transformational ;-).

Deep Self-Reflection – while people often turn to Rogers’ Curve[1] as a tool for classifying their colleagues’ response to change, it can be very helpful to recognize that we all have been ‘laggards’ at some point. Put another way, there has never been an idea for change that I came up with that I didn’t love! So, on a very basic level, thinking about how we have responded to ideas that another person has generated can be quite helpful. Reflecting on the principle that ‘we are all part of the system’ is also useful. Consider how your actions or inactions, your willingness to speak up or not, contribute to holding the ‘unchanged present’ in place. Finally, consider how to get honest feedback on your response to change – we all have ‘blindspots’ and require “ruthlessly compassionate partners who will tell the truth”[2] when we ask.

What do you think? Can we talk people into change or is it time to try listening?

[1] Rogers EM. Diffusion of Innovations. 4th ed. New York, NY: Free Press; 1995.

[2] Senge, Peter M. The Fifth Discipline: the art & practice of the learning organization. Crown Business, 2006.

Each offers a slightly different emphasis and all have their strengths. For me, all of these approaches come back to the heart of W. Edwards Deming’s teachings and philosophy. You can go back further still, but I find Deming to be the most useful foundation for the work. One reason is that his fourteen points for transformation of management offer the what but not the how of change – this allows for context sensitivity, i.e. adaptation and interpretation that respects the unique nature of organization. I also love Deming, because if you read him carefully, you will see that he emphasizes the relational side of improvement, while many specific strategies tend to focus on the technical.

So that is why I named my company the groundwork strategy. I want to get underneath the specific approaches and the sometimes-confusing language to help you understand the basis of systems improvement. From this strong footing, we can reach into whichever methods or approaches make sense to you, your organization, and the types of problems you are trying to solve. So no, I am not a purist when it comes to methods, let’s let the nature of the problem determine the best way forward and understand that in complex human service environments, it’s often best to bring all appropriate tools and techniques to bear.