There is a rigour to Lean thinking that can appear supremely cold and calculating. However, its unwavering focus on “what the customer sees as value” should curry favour with those who are receiving (e.g., paying for) the end product, which ideally equips companies to look after their people and their environment. Welcome to the triple bottom line.
See… it’s not all about the relentless pursuit of cost savings.
There are some very real inefficiencies (waste, or “muda”) that can be rid from any system with this approach. This may be part of the reason we are seeing such approaches embraced in non-traditional areas, including the service industry and, yes, health care.
The Flo Collaborative
The Flo Collaborative kicked off in September 2007 in order to examine and improve the flow of care in
Not surprisingly, many initiatives that offer the possibility for “quick wins” target frontline staff who are actively engaged in their current standard processes. Andrew Ward, Senior Manager at the Erie St Clair CCAC, worked on the pilot project in
Assessing and Influencing Authority
Asked about lessons learned in getting the all-important “buy-in” from “naysayers,” Andrew sees great potential in gaining involvement from the beginning. He says that it is well worth the initial investment in time to determine who has informal authority, in addition to those with formal authority. “No process change is made in a vacuum,” he explains. “Many things must be considered prior to making an adjustment in staff workflow.” Project leads and others within the team need to feel involved in order to want to share information.
There are some natural barriers that people can hit if they take a “business” approach to anything related to health care. Nonetheless, there are some significant improvements to be gained from a systematic approach, such as that with the Flo Collaborative. Like in any change initiative, it is ever so important to unlock the knowledge of the frontline by enabling good two-way communication. Andrew concludes, “By taking the time and identifying team members of formal and informal authority from the beginning, process changes will yield higher and more sustainable outcomes.” Don’t be mistaken: just because it’s soft, doesn’t make it easy.
This originally appeared in the June 2008 e-Newsletter for the Canadian Supply Chain Sector Council (www.supplychaincanada.org).
I had the very good fortune of hearing Deepak Chopra speak at the conference of the Ontario Association of Community Care Access Centres (OACCAC) this week. He was speaking to a room of various individuals involved in the delivery of health care at a community level, but his messages were wide sweeping.
According to Dr. Chopra, the trend toward well-being is the single biggest trend in the world today. He extrapolated to include economic well-being and environmental well-being, in addition to personal well-being. In short, people want the best end result to complex situations that include many interdependencies. In order to overcome the challenges of today, thus achieving well-being, we need to speak in non-violent metaphors. This demands a paradigm shift.
He navigated an impressive range of topics and, perhaps playing to his audience, spent a significant amount of time discussing biological and neural happenings. I say “perhaps playing to his audience” because he spent time as well on quantum physics.
The key message was indisputably focussed on the best way to bring about the best change. Given the state of the health care system–and that Ontario’s Minister of Health and Long-Term Care recently changed–the forum was a good one. The talk was teeming with fascinating insight and inspiring stories, but one of the most tangible pieces of advice that he shared was around leadership. Although Deepak Chopra leads a session on the Soul of Leadership at the Kellogg School of Business, the advice was accessible and applicable to all who were there… a “Micro Leadership” message, if you will.
Effective leaders do two things, according to Dr. Chopra: (1) self reflect to self understand; and (2) remain open to opportunity. (Although he says many leaders mention luck, he defines “luck” as opportunity meeting preparedness.)
Clearly if everyone adopted this line of thinking, things would be easier. Although many hung on his every word (and bought the book after), not all were or will be able to embody or sustain this approach. Those who do, have a responsibility to (1) focus on the greater good and (2) look for ways to merge opposing interests with those of the former. Tough work, to say the least. Here are but two applications from follow on sessions that I attended:
1. Dr. Joshua Tepper from Ontario Health Force spoke about opportunities and necessity to have medical schools and colleges breed practitioners with cross-discipline awareness. What better way to find new opportunities than to have more people working together. The functional disciplines will have to be very comfortable with one another and secure in themselves to be open to this. You can imagine all the reasoning for not collaborating: what is they start doing our work? who decides if we don’t agree?
2. Jeff Dolweerd discussed a LEAN case study underway the Central CCAC. The rigorous focus on value from the client’s perspective identifies clear ways to create value more effectively. In a situation where supply is staff and demand is uncertain, the answer lies in getting people to work more flexibly, both with hours and job roles. Sounds simple, until you run into a union mindset (like this one), which may not be able to open up to possibility. (Not to suggest that privatization is the answer; it is definitely a possibility!)
I thoroughly enjoyed Deepak Chopra’s talk and it set a perfect tone for the rest of the day, in my opinion. Not everyone will “get” or will be able to follow his prescription to lead. For those that do, given that we are very emotional beings, it may be tough to stay that course. According to Chopra “there is a creative solution to every problem.” I have cast doubt on that thought on this blog, but I have pause to reconsider now. It is there; we are all tasked to find it.
In working with a client recently, a hospital nurse relayed a situation to illustrate some of the conflicts that can arise between staff. The loose details are as follows: a patient is recovering in hospital and begins to feel nauseous in the middle of the night. The nurse records a prescription for Gravol on the chart. The following dialogue ensues during the doctors rounds:
Doctor: Who prescribed Gravol for this patient?
Nurse: I did; he was nauseous.
Doctor: Listen, I prescribe meds for patients, OK?
Nurse: (either out loud or internally) It’s Gravol! The patient was nauseous, and you weren’t around. Would you rather I let the patient vomit on themselves while I wait for you to come around and prescribe Gravol?
Behind this conflict, there may be several issues (interpersonal history, sleep deprivation, emotional strain of the job, frustration at poor handwriting, etc.). One of the issues may well be that this particular doctor does not respect the nurses full ability to provide insightful medical care. If the nurse suspects or understands this to be the doctor’s orientation, he/she has two options:
- Change the doctor’s orientation toward him/herself and toward nurses in general;
- Work around the orientation to get the right treatment for the patient.
The nurse pursuing Option 1 may face this interaction:
Doctor: Who prescribed Gravol for this patient?
Nurse: I did; he was nauseous.
Doctor: Listen, I prescribe meds for patients, OK?
Nurse: Gravol does not need a prescription. Since the patient is not allergic to Gravol, it was the best and safest answer. I am in a position to make that call.
Doctor: No you are not. Doctors make decisions.
Nurse: With all due respect, my training gives me the expertise to make this decision. This can allow you to focus on more serious issues. You would be my first contact if I had any uncertainties. With this patient, I believe this was the right approach.
Doctor: Doctors make decisions.
Nurse: …
The nurse pursuing Option 2 may find this:
Doctor: Who prescribed Gravol for this patient?
Nurse: The patient was nauseous; I suppose I should have written “nausea” on the chart instead of “Gravol,” but because the patient has had Gravol before, I didn’t see a problem.
Doctor: Just give me the information; I will make the decision, OK?
Nurse: Sure.
From the outside, it is objectively wrong and a misallocation of resources for nurses (or any other participant in a system) to not be allowed to make full use of their training and expertise. Although in selecting Option 2, you are enabling that misallocation, you are saving your time and energy with a work around solution. It is a trade off.
In a very real sense, objectivity allows you to pick your battles. You have the option, in some cases, of steering away from the “let me change your mind” conversation and still get the “right” outcome. It is a tough turn to take, but often an easier and faster resolution.
If you have read my blog before, please pardon me while I explain this question in view of not getting the “benefit of the doubt” from others reading this. I have worked in and with a wide range of health care organizations. As a citizen of Ontario with children, a spouse, siblings and parents in the province, I have a vested interest in the current and future system reforms working. I see a greater possibility for success if the right kind of collaboration takes place so that the right people are able to make the best (not easiest) decisions.
With that context, understand my sincerity in asking “What is it with doctors?”
In my writing and my client work, in- and out-group dynamics come up a lot. Doctors are perceived as a very specific constituency in the system… with good reason. The extent to which this perception stands is fascinating:
At lunch recently with a fellow consultant in the health care system said to me: “We seek to inform the doctors, but all we hope is that they don’t actively resist the work we are doing.” Working with a hospital group recently, the historic specter of the doctor vs. nurse divide reared its head. An academic mentor of mine with whom I consulted before launching my practice suggested: “It won’t work if you don’t get the docs on board, and I don’t think you will.”
There are a number of reasons why doctors could view themselves as very removed from the system: degree of training, stature that crosses most/all cultures, different employment structure with the hospital/community system, etc. But do they see themselves as that different? Some may, some may not.
If I were a doctor, I think that I would be proud of my accomplishments, and I might develop an ego. I also might think that it is my job to make decisions and may actually not appreciate what I perceive as challenges from other staff (RNs, RPNs, etc.) who (although they are only trying to help) are trying to make those decisions for me. What if they are wrong? If I were time starved, as many doctors are, I may not be able to take the time to “soften” my message or think about the “how” of my communication skills.
If doctors are removed from the workings of the system, they can take responsibility to “engage” more. If they don’t those working around them can accept the out-group reality and behave accordingly. The right information to save and prolong lives can still get through. Like many things, it is easiest if both sides work together. Some doctors will; some won’t or can’t. It is the latter group that could tip the scale one way or the other. As some of the tougher reforms come through, it will be interesting to see if the perception (and reality) of doctors change.
I was surprised to see that the lead story on CBC’s The National last night was about the fight for the right to use the Hockey Night in Canada theme song. I started to get suspicious when the story concluded with by suggesting that proposed the CBC could run a contest to pick another theme song.
As a student of the negotiation process, I thought I smelled a BATNA (best alternative to a negotiated agreement). The theory suggests that if you have a good BATNA, let the other side know it! And if you have a medium such as the CBC network, let others know it, too.
At first blush this BATNA seems pretty good, but when you think of the branding equity built up 40 years in “da da da da dah,” you quickly realize that the best is not all that good. When I was in grade 5, the city of Ottawa ran a contest for a city song. The winner was a really good song called, if memory serves, “Ottawa, the place to be.” I can’t recall hearing it since, and a quarter century out, I could find no reference to this song today, which is no surprise.
The contest, should it happen, would no doubt generate a great new song, jingle, theme, etc. Reality TV has proven there is some real talent in the masses. As good as it could be, it would not replace branding imprint of the predecessor. As the market for spectator sports gains competition from the likes of soccer, especially, I think the CBC should hang onto all the HNIC equity it can.
Without knowing both sides it is impossible to comment on the bulk of the negotiation, but from the public declaration of a viable alternative, I would gather the CBC has made a calculated bet to pressure a deal. I hope they get it, and I hope they realize what’s at stake.
“When is too much choice a bad thing?” is up for discussion in this front page story on the 2008 Congress of Humanities and Social Sciences. The argument put forward appears to be individuals that are given more choices do not necessarily obtain a result that is optimal for their preferences. In the era of “access to information,” individuals may find themselves unaware of the trade-offs that they are making. (e.g. A child should be given choices within healthy eating options rather than being given the choice of what to eat because children may not understand the consequences of eating, say, candy exclusively).
In retail transactions, I recall a friend of mine (A) was buying golf clubs through an employee purchase plan of his friend (B) who worked for the Canadian distributor. Like many employee purchase plans, you can get great stuff cheap, but you have to know exactly what you want. (Imagined phone dialogue; B is inputting data online.)
A – I want Driver, 3-wood and 3-iron through SW of Such-n-Such model.
B- Great. Right-handed; Standard length and lie, right?
A – You got it.
B – What shaft flex do you want?
A – Regular.
B – Where do you want the kick point?
A – What is that?
Obviously, you need a degree of sophistication to buy golf clubs this way; it’s the Dell model of “tell us exactly what you want; you will get it cheap.” I am afraid that cheap overshadows the value that others can add by making some decisions for you: “I shoot in the mid to high nineties. I tend to slice my driver, fairway woods and long irons. I will hit a good drive 280; and from 150 yards out, I swing a 6 iron. What have you got for me?” The knowledgeable retailer can steer me in the right direction, and gently try to sell me the clubs that are at the upper end of my budget, but I have to be ready to pay a little more.
The trends that remove the value-added information in return for lower costs (which is usually the trade-off), gives people more choice because they choose to choose. Do they realize that if you don’t know enough to choose what’s right, your satisfaction hinges on choosers being able to say “Can you tell me the difference between the two?” and choice-offerers having the knowledge to say, “Your choice here is really a trade-off between A or B?”
It may be the old claim that you can have it “cheap, good or fast, but you have to choose two of three,” re-written as “do the work up front to know what you need, then tell me; OR pay a little more and I will translate your wants into what you need.” Again, trust has no small role in these exchanges because you have to trust that the person is looking out for your best interest more than their best interest.
There should be no mystery as to why more choice reduces satisfaction. It takes a lot of work to be informed enough to make those decisions.
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