Thursday, March 24, 2011

I've always done it that way.

“Curmudge, today’s title looks as if it might be a sequel to last week’s We’ve always done it that way.”

“Very perceptive, Jaded Julie. Let me give you a ‘heads up.’ Today’s lesson is that standard work is more efficient, less costly, and usually easier than when everyone does things as they have always done them in his or her own way. Most importantly, standard work enhances patient safety.”

“That sounds intuitive, Curmudge, but I’ll bet that you have some evidence to back it up.”

“You recall my mentioning my senior citizen friends that I see every Independence Day. Although it’s depressing, we often talk about health issues. It is discouraging to learn that among that group and my other friends and acquaintances, many people have incurred surgical site infections. Of course these people were the fortunate ones, because they lived to tell about their experience. My circle of close friends is small (and its diameter is being reduced by the Grim Reaper); but even without hard data, the frequency of these presumably preventable infections is shocking.”

“So much for anecdotal evidence. There must be some information out there that supports your thesis that standard work makes patients safer.”

“Have patience, Julie, we’ll get to it. It’s my understanding that individual surgeons favor specific instruments, sutures, prosthetic devices, and other replacement parts for a given procedure. This is called their ‘preference list.’ So surgeon A would have his/her preference list for procedure X, while surgeon B might have a different list for the same procedure.”

“That doesn’t sound like standard work to me. But it’s not surprising, because surgeons A and B might have learned the procedure from attending surgeons in institutions hundreds of miles apart. In each case, the surgeon might say about his technique and preference list, ‘I’ve always done it that way.’ That must be pretty common, Curmudge, but how does it relate to surgical site infections?”

“In his leanblog.com posting on March 7, 2011, Mark Graban cited a study of a procedure that historically yielded from 2 to 5% frequency of surgical site infections. At the start, the study group members used 14 different pre-printed order sets for the same procedure. After weeks of deliberations, the surgeons and anesthesiologists reached consensus on standard order sets.”

“Wow! Those meetings must have required a talented facilitator. What was the outcome of their having adopted standard infection control procedures?”

“The study group went 11 months without a single occurrence of the target infection. And when a single infection ended their record, the group was able to investigate its root cause without blaming an individual. Overall, their surgical site infection rate dropped 63%. Furthermore, the team agreed that they would make changes that are best for the patient rather than the provider.”

“That’s really impressive. It’s critical to realize that the changes were made by the physicians themselves. They most likely would not have been adopted if they had been imposed on the physicians by someone else. By the way, Curmudge, do you have a standard procedure for writing this blog?”

“Sometimes I ruminate on a topic for weeks; sometimes for only a few minutes. Then I just sit at the computer and write. I’ve always done it that way.”

Affinity’s Kaizen Curmudgeon

Friday, March 18, 2011

Kaikaku, a countermeasure for "We've always done it that way."

“Jaded Julie, here’s a new Japanese word for you to learn. It is kaikaku, meaning radical or transformational change.”

“Another word! Curmudge, I thought we topped off my Japanese vocabulary years ago.”

“Now Julie, you’ve known for a long time that there are single words—in several languages—that substitute for phrases, sentences, or even paragraphs in English. Often there is no comparable English word, and the foreign word says exactly what we want to express.”

“I get it, Curmudge. We have already learned that gemba is the workplace or ‘where the action is,’ and muda is waste that comes in at least eight varieties. And of course, kaizen, ‘continuous improvement’ or ‘small changes for the good,’ is one of the central principles of Lean. So why kaikaku? Doesn’t kaizen cover all the changes that need to be made?”

“Not always. Think of the all-too-common expression, ‘We’ve always done it that way.’ That statement usually represents a historical practice that was implemented without a lot of forethought and has been ‘grandfathered’ into everyone’s thinking. To a change agent, that is abhorrent and is a candidate for immediate evaluation and perhaps radical change.”

“Okay, armchair insurgent, please provide an example.”

“Julie, we talked about this back on July 16, 2009. It was part of our series of postings on queuing theory and level loading or heijunka. Scheduling—especially in hospitals—tends to follow tradition and leads to hills and valleys in people’s workloads, i.e., poor heijunka. Because this is a big, always-been-done-that-way problem, it would require a big, kaikaku countermeasure.”

“Does kaikaku always refer to a big change applied to a big problem?”

“Not always, Julie. The critical difference between kaikaku and kaizen is timing. Kaikaku is quick and total; kaizen is continuous and incremental. Not all processes can be changed incrementally. For example, if you are taking your car through the ‘chunnel’ from France to Britain, you drive on the right in France and immediately change to the left in Britain.”

“Okay Rick Steves, but do you have a Lean example?”

“If a three-day or one-week small-team ‘kaizen’ or rapid improvement event yields a clear, definitive solution to the problem at hand, that’s a kaikaku. We’ve heard about a lot of these in our monthly kaizen report-outs. On the other hand, if a favorable outcome will require incremental improvements and several plan-do-check-act cycles, that’s kaizen.”

“Let’s get real, Curmudge. Does it truly matter which word we use, kaizen or kaikaku?”

“Probably not, but it might if you are Japanese. Here’s a different sort of problem. Suppose you are involved in an effort that ends up with neither a kaikaku nor a kaizen. Unfortunately, some of these might begin as a kaizen event, get bogged down because the traditions are so strong, and end up where they started—doing it the way it’s always been done.”

“And do the Japanese have a name for those?”

“Very likely, but as in English, it would be too profane for posting in Kaizen Curmudgeon. Maybe we should call those ‘teachable moments’ and return later in our Lean journey to tackle the seemingly intractable problems.”

“Old Guy, it has occurred to me that not all traditions are bad. Here’s a good example of something that has always been done that way. On Fridays we’d knock off work early and enjoy some Gemütlichkeit, ‘good living’ in German, at a local oasis.”

“At my age, Julie, my kaikaku for traditional Gemütlichkeit is to go home and go to bed early.”

Affinity’s Kaizen Curmudgeon

Thursday, March 10, 2011

Complacency 2

“Wake up, Curmudge! It’s too early for your afternoon nap.”

“I’m not napping, Jaded Julie. I’m concentrating on our colleagues’ one-page papers and trying to extract lessons that are worthy of being shouted from the roof of the hospital’s parking structure. As in last week’s posting we are sharing with our readers portions of our guest authors’ interpretations of John Kotter’s quotation, ‘Never underestimate the magnitude of the forces that reinforce complacency and that help maintain the status quo.’ Now it’s Rick’s turn. He focuses on the threat of complacency following a critical period in the life of an organization.”

“Kotter lists nine sources of complacency, but I want to briefly describe two that are intertwined. They are, ‘Absence of a major and visible crisis,’ and ‘Too much happy talk from senior management.’ I recall the story that our CEO told our Lean class, ‘Several years ago the threat facing the organization wasn’t how to take the next step in our growth as an organization, but rather how to avoid taking our last step as an organization.’ Wow! That really grabbed our attention. At that point, there was most definitely a major and visible crisis, and senior management certainly wasn’t bragging about the bright future of Affinity. There were tough decisions that were made and hard work that was done and Affinity is now in a stronger position. However, now that the existential danger is lessened, a new threat, complacency, may be present out there in the organization. We need to praise all the hard work and success that everyone made to get us to our current position. But by doing so, do we risk negating the sense of urgency within the organization that is needed to make the next step? The threat is that we might rest on our laurels because the danger of the organization’s collapsing appears to be no longer imminent.”

“The other part of our newer colleagues’ assignment was to explain how they would use Lean to manage their staff in challenging the status quo. In brief, they have been asked to present a problem with complacency—as they have done above—and then propose appropriate countermeasures. Since Rick just described his problem, let’s read how he will tackle it.”

“The challenge facing the organization is to make sure that we don’t lose our sense of urgency. We need to develop Lean leaders that have the self-motivation and internal urgency to be the best. With those qualities, they will retain our focus on the corporate vision.”

“I believe what he is saying is that middle managers’ dedication to Lean must be visceral.”

“My knowledge of anatomy is pretty sketchy, Julie, but I suspect that in this context, visceral is the same as hard-wired.”

“I believe we all agree with Justin, who feels that the most effective way to challenge staff in implementing change is to create a high sense of urgency.”

“To effectively change the status quo, you must start to change culture, which is typically is very difficult to accomplish. Escalating the sense of urgency counterattacks complacency in individuals who are not resistant to change. This escalated sense of urgency pushes individuals to the edge of their comfort zone and reiterates the need for change. The sense of urgency should also make it difficult for employees to revert back to their old habits, either by eliminating the possibility or by encouraging a need of abandonment.”

“Ieva maintains a sense of urgency not by injecting Lean into an existing system but by totally changing the system. In this case, the change is from traditional primary care to the Medical Home model.”

“In my role as a Lean coach, I have committed to bring this sense of urgency to life by teaching and helping our staff look at our processes with new eyes. I specifically have been blessed to work with our Medical Home sites in implementation of a new care delivery model. While it is easier to spot changes that need to take place at the new sites, I continuously challenge our existing Medical Home sites to look at the new and improved processes and evaluate and adjust as needed. We do not always figure out the best way first—there is always improvement to be had.”

“We haven’t quoted Jerry in this posting yet, but I believe he has a viable countermeasure for incorrigible resisters to change.”

“There are mindsets in organizations that are rooted so deeply that they are nearly impossible to change unless they are eliminated through a transformation, total renewal of mind, or in some cases radical surgery.”

“It sounds as if sometimes people just have to be asked to ‘get off the bus.’ That seems pretty harsh.”

“Congratulations, Curmudge. For once you used a five-dollar word, ‘harsh,’ when you might have used a ten-dollar word, ‘draconian.’ But tell me Curmudge, are we going to post our guest authors’ writings on complacency and change leadership without putting in our own two cents?”

“We have been there and done that three years ago, Jaded Julie. I hope you haven’t forgotten our postings on Change Leadership for Middle Managers.”

Affinity’s Kaizen Curmudgeon

Thursday, March 3, 2011

Complacency

“Curmudge, if you were going to give just one book to a new Lean Coach-in-Training, what would it be?”

“Without question, Jaded Julie, it would be John Kotter’s Leading Change. But you know that I am too cheap to buy a book for every hard-working, intelligent, and talented person to come down the pike.”

“Okay Scrooge. What would you recommend?”

“Of course I’d recommend Kotter’s book, but for someone who is short of time and money, I’d advise reading Kaizen Curmudgeon. And a good place to start would be our posting ‘way back on October 29, 2007, A Funny Thing Happened on the Way to the Transformation.”

“Well as it turns out Curmudge, the newer members of our team already have Kotter’s book, and they have been asked to write about a topic close to John Kotter’s heart, complacency. Furthermore, they are willing to contribute their writings to Kaizen Curmudgeon.”

“Guest authors? Saints be praised; it’s a miracle!”

“The specific assignment for the new Lean coaches is to explain in their own words Kotter’s statement,’Never underestimate the magnitude of the forces that reinforce complacency and that help maintain the status quo.’ Here are their one-page papers, Curmudge, but please spare the red pencil when you edit them.”

[Later] “The first thing I noticed, Julie, is that no one has defined complacency. We’d better do that: ‘A feeling of quiet pleasure or security, often while unaware of some potential danger; self-satisfaction or smug satisfaction with an existing situation.’ With the help of dictionary.com, we all should now be on the same page.”

“Let’s start with Ieva’s contribution, slightly edited. Despite her European heritage, it looks as if she started writing English composition at the age of three.”

“Instead of looking at others, I would like us to take a look at ourselves. Our organization adopted the Lean philosophy approximately four years ago and has come a long way in not only talking but also walking Lean. Even with impending health care reform, we feel that our present organization is a good place to work, is competitive, and provides outstanding care to our patients. Sounds complacent?? …Perhaps. This is how easy it is to slide down the slippery slope of complacency. Complacency is not a single sin that we commit; it is comprised of various elements that usually involve human nature, happy messages from senior management, low overall performance standards, and internal measurement systems that focus on the wrong performance indexes. We have been diligently working on aligning our goals and strategies and also set our bar high when it comes to metrics. But still, once in a while, we encounter the presence of the ugly ‘c’ word, complacency. As Kotter wrote, ‘People will find a thousand ingenious ways to withhold cooperation from a process that they sincerely think is unnecessary or wrongheaded.’ Thus other people’s complacency—or even obstruction—may be out there, but we might be too self-satisfied to realize it. Even high performing organizations can slip into the lull of ‘we are doing so great.’ The above quote to me means that we need to always be vigilant and aware that despite our progress, we may not let our guard down and feel that we have ‘finally made it.’ The sense of urgency needs to be ever present in our actions to ensure that we do not become too comfortable.”

“Justin takes a somewhat different tack. He believes that Kotter was writing about the difficulty in changing the culture in an organization, specifically addressing those individuals who don’t actively resist change, and who don’t necessarily support it either.”

“In a well-established organization, the cultures and habits of employees can be difficult to change. Employees who have had exposure to current corporate culture my actively resist or thwart efforts to implement change. These characters are obviously the easiest to identify, due to their visible determination to disrupt change, and are usually the clear target for ‘reeducation’ by those implementing change.

In addition to the employees who actively resist change, there are also those who don’t voice their opposition to change. They might even verbally agree with the proposed changes, but act in a way that doesn’t support them. There could be many ways these types of employees discourage change, such as: overstating performance measures, rigging surveys and systems to ensure no issues arise, downplaying or denying crises, and denying the urgency for change. These individuals are subtle in how they enhance complacency, and are usually difficult to immediately identify. They often pose a larger risk to change than those who actively disapproved of it because they quietly but persistently spread their views to others. Kotter states ‘… those who were relatively unaffected by complacency … and thus concerned about the firm’s future were often lulled back into a false sense of security by senior management’s ‘happy talk.’’ Senior management may unintentionally discourage the need for change by influencing those who once believed change was urgent.”

“Curmudge, it seems to me that Kotter was being overly tough on management. Managers have to walk a tightrope between sharing good news when the news is good and reducing the sense of urgency.”

“Speaking of tightropes, Julie, you and I must be careful in our editing that we don’t discourage the writers from future participation.”

“Hang in there, Curmudge. As a last resort, we can say that you really are a curmudgeon, i.e., a nasty old man. Meanwhile, let’s invite our readers to come back next week to read the work of more guest authors.”

Affinity’s Kaizen Curmudgeon