James (Beau) Keyte, Judy Worth & Tom Shuker
By Mark Graban
By John Toussaint, MD
Healthcare teams in the U.S. include some of the brightest, most passionate, and most dedicated people of any industry. Yet healthcare is also one of the most unreliable industries. Three Sigma quality is the norm. This year alone over 250,000 Americans will die due to medical error.
How can so many smart people be making so many terrible mistakes? Broken processes are the cause of most mistakes in healthcare. Why are healthcare processes broken? The root cause, in my experience, is the prevailing healthcare management system.
Top-down management beauracracies are the norm in healthcare today. There is little room for frontline problem-solving because managers and executives covet making every decision. If a worker has an idea for improvement it lands on a middle manager’s desk – lost in the chaos of the week. But fortunately, a few bold organizations are scrapping prevailing management and replacing it with a system W. Edwards Deming described as “management by process.”
Management by process is anchored in a core set of pre-established principles. I outline these principles in my new book Management on the Mend. They are derived from the Shingo Model and are critical to a successful transformation journey. So much of what I see in hospitals today is a tool-based approach to lean transformation. The theory goes, “If we just do enough kaizen events we can transform the culture.” This is far from the truth and never achieves the goal of true transformation. Building a management system based on principles hardwires key cultural attributes into organizations.
For example, at Alta Bates Summit Medical Center, Summit Campus in Oakland, California, patient care unit managers meet with nurse leads on the floor every morning to discuss the “status” sheet. This is a process of inquiry that is based on the principle of respect for every individual. The respect is shown as the manager acts to deeply understand the problems the nurses are facing for the day, encourage and coach them to identify and solve the problems. They then remove any barriers for care delivery. Managers report this process has significantly reduced firefighting because potential problems are proactively identified ahead of time. Senior leaders have similar conversations with managers, as does the CEO with senior leaders. In this way everyone in the management ranks is having dialogue about how to better care for patients that day. This is one component of the standard work for managers and executives.
There are different roles and responsibilities at every level of management. At senior management level, the principle of defining clear purpose is used to create clarity for everyone else in the organization. I visited a hospital a few months ago that had 248 strategic initiatives. That is simply confusing. A process must be developed by executives to de-select projects and initiatives. If this is not accomplished, front nurses and managers have no hope of getting to daily problem-solving. All they have time for is senior management’s initiatives as well as their first duty of getting through the busy day of patient care.
Defining purpose also means establishing the metrics that will guide the work. In another organization, I observed 55 “True North” metrics. True North is the few metrics that really matter. Choosing 5-8 is hard, but necessary. If employee injuries are occurring every day (in most hospitals this is true) choosing injuries as a True North metric makes sense. The metric relays to everyone in the organization what matters. In this case, creating a culture of safety.
The principles of scientific method for problem-solving and quality at the source lead to building expertise in the organization to support radical redesign. Creating the central improvement office is the system for developing the expertise. The role of these experts is not to solve problems, but to teach leaders how to facilitate the efforts of frontline workers to design and rapidly improve processes. This requires them to learn how to see waste and remove it. By unleashing the creativity of workers with these systems, new models of care delivery emerge.
For example, Rick McKenzie, MD; lean facilitator Chris Kita; and the team at Lehigh Valley Hospital-Muhlenberg, part of the Lehigh Valley Health Network in Allentown, Pennsylvania, were able to get many clinicians involved in the development of their new ER. The redesigned ER has nine chairs in the waiting room. This 75,000-visits-per-year ER essentially has no patient waiting. Patients are immediately triaged when entering the ER and moved to one of three flows. The new process assures quality is built in with no waiting - and immediate diagnosis and treatment. Using rapid cycle plan-do-study-act cycles, the new ER was created in a few short months by front line staff. Eighteen million dollars in costs was avoided by not having to build a new ER and ambulance diversions went from 50 hours per month to zero.
Lean is a cultural transformation – not a tool set. Principles lead to the development of systems that change behavior (culture). Hospitals taking this approach are beginning to create measurably better value for their patients. Courageous healthcare leaders throughout North America have pioneered the way. It’s time the rest of healthcare catches up.
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