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The Question All Healthcare Leaders Should be Asking Themselves

by Mark Graban
January 15, 2014

The Question All Healthcare Leaders Should be Asking Themselves

by Mark Graban
January 15, 2014 | Comments (10)

Are we managing the system?

Leaders in healthcare organizations are increasingly understanding the message that, as W. Edwards Deming taught, a vast majority of problems are caused not by individual people or even individual processes, but by the system. And, as Dr. Deming said, "A system must be managed. It will not manage itself." This is a great lesson, one that should be applied everywhere, but is possible the most important in the context of lean healthcare.

A common problem I run across in hospitals is that "hourly rounding" for inpatients doesn’t get completed anywhere close to 100% of the time. This means patients aren’t consistently checked on at least once every 60 minutes. That can lead to lower patient satisfaction, not to mention increased patient harm (such as falls that occur when patients try to get up to use the bathroom when they shouldn’t get out of bed without assistance).

When a problem happens and harm has occurred or a patient satisfaction score is discovered to be low, a hospital or a particular department leader might react by saying, “It’s a system problem.” They might embrace that part of Dr. Deming's lesson by not looking to blame or punish the nurse and/or tech who were assigned to the harmed patient and then move on without realizing it's their responsibility to manage and improve the system.

One hospital I worked with struggled with hourly rounding. This task was part of their standardized work, in a way. But they didn't have a well-designed standardized work system and there were regularly more tasks than could be completed in any 60-minute period. The managers did not know this because they weren't present at the gemba (the place where the work happens), as they were in meetings or catching up on mail most of the time.

When I walked through the unit with a nurse, I could see the checksheets that were posted outside of each patient room. Another element of their standardized work was to mark each hour throughout the day as hourly rounding had been completed. But at 3pm it was clear as day that there were many blank checkboxes between 8 am and 3 pm. I saw a manager walk by—she was actually in the unit, so that was at least a good start—but she walked past all of the blank check boxes. In this case, the manager was present in the gemba, but didn't have her eyes fully open and she was  not actively managing the system. Reacting to these visible problems is a good first step, but the manager must also manage the system in a way that prevents future problems from occurring. 

In a really good car plant (not just Toyota), if a worker cannot complete their 60-second job in 60 seconds, they reach up and pull an andon cord. A team leader comes within a few seconds to ask how they can help. The last thing they would ever do is skip a step! If a door isn’t attached in time, it’s really obvious that the door has not been attached. (This is because the car plant has the type of product and process where many problems and defects are easily visible).

In a hospital, many of the problems and defects are invisible. The checksheet is an attempt to make problems visible. But once a problem is visible, a manager then needs to step in to help. In each individual unit, the manager should be able to see that boxes are not checked. Yelling at somebody, "We told you to do hourly rounding!" doesn’t help. That's ineffective, just as much as ignoring the problem or not noticing the problem in the first place. And yelling may create fear that it’s not ok to acknowledge problems, perhaps leading people to check the boxes even if they hadn't completed the task. 

In a Lean hospital, the manager asks questions. Is the hourly rounding being done, but not documented? If so, do staff understand why it must be documented in the first place? If the hourly rounding is not being done each hour of the day, why is that? What are the barriers that get in the way? How can the team work together to reduce waste to free up time so that nurses and techs actually have the time to do hourly rounds and more than that, don't have more than 60 minutes worth of work to try to do in an hour? 

Blaming individuals for system problems isn't Lean, but more importantly it's not the way to improve quality. Nor does ignoring (or not seeing) the system problem help. Managers need to be present, with their eyes fully open to see problems and always asking questions. And then managers’ ears must be open to hearing the answers to those key questions they should be asking. This is the only way they’ll begin to effectively manage the larger system.

Learn how lean tools and philosophy work together to create a lean healthcare system. Join Mark Graban for Key Concepts of Lean in Healthcare, a live webcast workshop beginning February 11. Learn what’s covered.

The views expressed in this post do not necessarily represent the views or policies of The Lean Enterprise Institute.
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10 Comments | Post a Comment
Barbara January 15, 2014
1 Person AGREES with this comment
The system is  a good one but the unlicensed staff is imtimidated fearing retribution and most often won't communicate or ask questions of liscensed personnel. They dont want to get  written up.  

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Mark Graban January 15, 2014
Thanks for the comment, Barbara. I understand what you mean about staff (licensed or not) being afraid about speaking up. Nobody feels comfortable speaking up to say "I have too much work to do right now" because they are afraid they'll be labeled as a bad employee. If managers have created an environment where people are afraid (and patients suffer as a result), that's hardly a "good" system. It's a mess.

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Danielle McGuiness January 15, 2014
1 Person AGREES with this comment
i love that you mention a checksheet in that it makes me think of Atul Gawande's book "The checklist." It's a great read.

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Mark Graban January 15, 2014

Thanks, Danielle. It's the type of checklist that's supposed to help verify that things were done (or not done) after the fact (as opposed to a checklist that prompts you to do things as you go).

The checklist itself (in any setting) is only as good as the management oversight and response to it... 



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Michael Lombard January 16, 2014

The hourly rounding issue is a great example to use.  Even when a hospital achieves consistency in rounding every hour, the way the round is performed can be highly variable.  We can utilize a standard script of questions for each hourly round, but if our nurses are constantly interrupted by calls during the process then it can become hit-or-miss in terms of following the standard work.

What's most interesting, however, is that these disruptive calls are from other patients, and oftentimes they are calling because something got missed during the hourly rounds...because we didn't follow the standard work...because we were interrupted.  It's some sort of "tragedy of the commons" or Catch-22 situation; I'm not sure which.

It appears that in this situation our clinical leaders will need to find a way to intervene in order to artificially limit disruptions...so we can get back to standard...so we can proactively address our patients' needs...so we can preempt disruptive calls during hourly rounds.


Of course, to your point, if we don't have the management systems in-place (andon, visual controls, etc.), we will be slow in recognizing the need for such interventions and may resort to old-fashioned solutions:  more accountability, more training, etc.



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Mark Graban January 16, 2014

Yes, there's a vicious cycle... doing hourly rounding is pretty well proven to SAVE time for nurses because there are fewer reactive call lights, etc. "We don't have time for hourly rounding" is often due to not doing hourly rounding...

Managers and directors (and VPs and up) need to see the problem (hourly rounding not being done) and then talk with people and work together with them to solve that problem (the ultimate goal is not "hourly rounding" but better patient care, outcomes, and satisfaction).



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Mike Steinberg January 16, 2014
1 Person AGREES with this comment

Mark, you are spot on. In any industry, leadership can play a positive role in improving both production and employee/customer satisfaction. In healthcare, as you mentioned. many times the problems are "invisible" and they need to be sought out by Leadeship through Gemba walks and questioning staff in a supportive manner. Once the answers to issues surface, and standardized work is created, make sure that staff has the proper training, tools and techniques to be succesful. Thank you for beating the drum to get out of the office and supportively entering the work area.

Mike



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Denis January 17, 2014
1 Person AGREES with this comment
Interesting Article. We too have incorporated best business practices and commitment to the kaizen techniques and innovation solutions to achieve world class manufacturing standards.

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James Perdue February 27, 2014
A friend related this story: he was diagnosed with a failed heart valve, which needed immediate attention. In terror, he began researching (on line) all he could find regarding the impending open-heart surgery. In so doing, he found that the hospital, where his surgery was to be performed, had a high HAI rate. He spoke to his physician and was told "don't worry about it." He did worry about it, and canceled the surgery - then began researching other hospitals. By the way, the local cost of the surgery was $200,000 and 6 weeks off work.
He found another hospital (out of state) which had a "statistically unmeasurable" HAI rate. He got his insurance to agree to the surgery in another state, when they found that the fee would be $100,000. AND, he would be off work for 2 weeks.
It's been over a year since his surgery, and he now has his checkups, again out of state, near the beach with airfare, hotel, and checkup costing less than half of the local hospital.
The hospital that did his surgery uses lean principles.
Can the country solve its health problems if the costs are cut in half?


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Mark Graban March 10, 2014

There are enormous and inexplicable differences in the cost of healthcare delivery -- across the country, across our own state, and even within the same city/metro region.

The lowest cost care tends to also be the highest quality care, when the data is available to even tell.

So, yeah, we don't need to spend MORE... we need to reduce the waste and reduce costs and we can all benefit. 

That's the promise of Lean in healthcare. But, it's not just Lean tools that we need... it's a culture change where healthcare leaders realize that this level of transformation is even possible and where leaders actually become willing to learn from the examples of ThedaCare, Virginia Mason, and others who have demonstrated that we can dramatically improve the safety and quality of health care while also reducing costs quite significantly.



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