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.