“So, Curmudge, what more are we going to learn from Hôpital Nord 92?”
“Jaded Julie, I hope we’ll learn more about safety and efficiency in nursing.”
“By the way, Curmudge, how does one say 92 in French?”
“Quatre-vingt-douze. It means four twenties twelve. Why do you ask?”
“Well, their math is okay, but it’s sure not a very efficient way to say ninety-two. Can the French really teach us anything about efficiency?”
“You’re in luck, Julie. Ballé and Régnier cite an American author, Steven Spear. Dr. Spear contends that ambiguity and workarounds contribute to medical errors*. They are also undeniable sources of inefficiency. Think of what must be known for any process to occur: who (patient as well as caregiver)? what? when? where? why? how? Ambiguity in answering any of these questions leads to inefficiency and time wasting. If root causes of problems in a process or procedure are not resolved, workarounds must be developed each time it is performed.”
“I can certainly see that ambiguity can lead to inefficiency, but in what ways might it compromise patient safety?”
“Answering the ‘how?’ question is one of the most critical. Here’s what people tend to do when they are uncertain about how to do something (from a seminar at SEH by Lucia Berte):
· They ask someone.
· They look it up (if the document is easy to interpret and not too long).
· They make it up.
· They might not do it. (In Nord 92, the nurses sometimes skipped steps in procedures.)”
“Wow, Curmudge, the last two options are kind of scary. I can understand how they might lead to errors. So how did the nurses at Nord 92 respond to Dr. Spear’s teachings, especially his urging that patient care practices be highly specified, i.e., standardized?”
“Because checklists had been developed in order to achieve the basic stability that we discussed last week, the nurses were familiar with the concept. They were, as might be expected, protective of their autonomy and reluctant to use checklists on themselves. So the effort started on a small scale with a checklist on basic patient care. Early checklists likely avoided topics that might be considered efforts to standardize nursing judgment. Later, however, the program grew to standardize more technical aspects of patient care.”
“It sounds as if the folks at Nord 92 jumped headlong into the Toyota Production System.”
“They did, Julie. And they used some other Lean techniques that we’ll cover in later discussions. Remember that they accomplished all of this using teams of nurses guided by their managers. If these changes had been dictated by management, they would have been accepted about as fast as if they had been written in German (or maybe in English).”
“The French have taught us a valuable lesson. After basic stability is achieved, standard work can be applied to patient care. Say, Curmudge, do you have any other examples of French efficiency?”
“Sure. Est-ce que at the beginning of a sentence means that the sentence will be a question. You don’t have to wait for the question mark at the end.”
“Well, that’s not as efficient as the inverted question mark (¿) in Spanish.”
“Good observation, but did you ever hear anyone speak an inverted question mark?”
“Hey! That’s pretty quick for an old guy. See you after your trip, Curmudge?”
“Of course, Julie.”
Affinity’s Kaizen Curmudgeon
*http://www.annals.org/cgi/reprint/142/8/627.pdf
P.S.—“Check this out, Julie. It’s a timely blog posting that provides strong support for standardized processes in patient care.” http://www.dailykaizen.org/archives/564
Tuesday, July 29, 2008
Thursday, July 24, 2008
Lean in a French Hospital
“Have you ever been in a French hospital, Curmudge?”
“No, Jaded Julie, but we came very close. Mrs. Curmudgeon contracted food poisoning in Paris several years ago. We stayed in the hotel because my wife was too sick to move—except frequently to the bathroom. I went to the local pharmacy, and the pharmacist provided something that seemed to be effective. Perhaps pharmacists there can dispense without a prescription more powerful stuff than here. Although my wife felt like dying, she eventually got better.”
“It sounds as if the French have become more helpful to Americans than in years past.”
”I suppose so. You can depend on the French; they are always there when they need us.”
“Curmudge, did you say that right? Considering the source, I guess you did. So anyway, tell me about the paper you found—the one about a hospital in France.”
“I was googling ‘Lean in nursing’ and encountered the paper, Lean as a Learning System in a Hospital Ward. I’ll give you the URL*, but Word refuses to open the file. Perhaps it has the same French bug that my wife had. At least it can be accessed via Google.”
“Please proceed, Professor. We’ve already used a half page.”
“The staff at the hospital, Hôpital Nord 92, used Lean tools, especially 5S, and encountered what the authors call the ‘pillowcase syndrome’. If one squeezes at one end, it bulges elsewhere. When they made an isolated improvement, it shifted the burden to another element in the system. The authors, Ballé and Régnier, attributed their lack of meaningful progress to the lack of basic stability in their unit. Although the ‘basic stability’ problem has been described by Smalley in the manufacturing context**, it can be translated into health care.”
“Okay, Curmudge. I think at this point you want me to ask, ‘How can one achieve basic stability in a patient care unit?’”
“The folks at Park Nicollet Health Services in Minneapolis provide some inspiration in their listing of the ‘7 Flows of Medicine’***. These are factors that they consider in designing changes in processes or delivery of services:
· Flow of patients
· Flow of providers
· Flow of medications
· Flow of supplies
· Flow of information
· Flow of equipment
· Flow of instruments and processes”
“I think I get it, Curmudge. The better one can control these flows, the greater the unit’s basic stability. Did the nurses at Nord 92 improve any of their flows, perhaps without even knowing of Park Nicollet’s list?”
“Yes, they really made significant progress toward basic stability. They initiated a ‘clear corridor’ policy so that wheelchairs and trolleys (carts) were properly located and not scattered all over. Materials handling and storage were studied and improved. They adopted a ‘supermarket’ (first in, first out) policy for storage areas. A clear benefit of these changes was that anything out of date or out of place would stand out. Success in these projects convinced the nurses that there might be value in achieving basic stability in nursing care itself. At the end of the paper, the nurses were developing checklists and devising what we would call ‘standard work’ for some of their processes and procedures.”
“That’s great, Curmudge. I understand that we’ll talk more about Nord 92 in our next conversation. By the way, did your wife ever return to Paris?”
“Never. And she refuses to eat foie gras.”
Affinity’s Kaizen Curmudgeon
*http://lean.enst.fr/wiki/pub/Lean/LesPublications/HospitalLearning.pdf
**http://www.superfactory.com/articles/Smalley_Basic_Stability.htm
***http://www.msp-ifma.org/0702prgnotes5S3PLeanCaseStudyDSpiegle.ppt
“No, Jaded Julie, but we came very close. Mrs. Curmudgeon contracted food poisoning in Paris several years ago. We stayed in the hotel because my wife was too sick to move—except frequently to the bathroom. I went to the local pharmacy, and the pharmacist provided something that seemed to be effective. Perhaps pharmacists there can dispense without a prescription more powerful stuff than here. Although my wife felt like dying, she eventually got better.”
“It sounds as if the French have become more helpful to Americans than in years past.”
”I suppose so. You can depend on the French; they are always there when they need us.”
“Curmudge, did you say that right? Considering the source, I guess you did. So anyway, tell me about the paper you found—the one about a hospital in France.”
“I was googling ‘Lean in nursing’ and encountered the paper, Lean as a Learning System in a Hospital Ward. I’ll give you the URL*, but Word refuses to open the file. Perhaps it has the same French bug that my wife had. At least it can be accessed via Google.”
“Please proceed, Professor. We’ve already used a half page.”
“The staff at the hospital, Hôpital Nord 92, used Lean tools, especially 5S, and encountered what the authors call the ‘pillowcase syndrome’. If one squeezes at one end, it bulges elsewhere. When they made an isolated improvement, it shifted the burden to another element in the system. The authors, Ballé and Régnier, attributed their lack of meaningful progress to the lack of basic stability in their unit. Although the ‘basic stability’ problem has been described by Smalley in the manufacturing context**, it can be translated into health care.”
“Okay, Curmudge. I think at this point you want me to ask, ‘How can one achieve basic stability in a patient care unit?’”
“The folks at Park Nicollet Health Services in Minneapolis provide some inspiration in their listing of the ‘7 Flows of Medicine’***. These are factors that they consider in designing changes in processes or delivery of services:
· Flow of patients
· Flow of providers
· Flow of medications
· Flow of supplies
· Flow of information
· Flow of equipment
· Flow of instruments and processes”
“I think I get it, Curmudge. The better one can control these flows, the greater the unit’s basic stability. Did the nurses at Nord 92 improve any of their flows, perhaps without even knowing of Park Nicollet’s list?”
“Yes, they really made significant progress toward basic stability. They initiated a ‘clear corridor’ policy so that wheelchairs and trolleys (carts) were properly located and not scattered all over. Materials handling and storage were studied and improved. They adopted a ‘supermarket’ (first in, first out) policy for storage areas. A clear benefit of these changes was that anything out of date or out of place would stand out. Success in these projects convinced the nurses that there might be value in achieving basic stability in nursing care itself. At the end of the paper, the nurses were developing checklists and devising what we would call ‘standard work’ for some of their processes and procedures.”
“That’s great, Curmudge. I understand that we’ll talk more about Nord 92 in our next conversation. By the way, did your wife ever return to Paris?”
“Never. And she refuses to eat foie gras.”
Affinity’s Kaizen Curmudgeon
*http://lean.enst.fr/wiki/pub/Lean/LesPublications/HospitalLearning.pdf
**http://www.superfactory.com/articles/Smalley_Basic_Stability.htm
***http://www.msp-ifma.org/0702prgnotes5S3PLeanCaseStudyDSpiegle.ppt
Thursday, July 17, 2008
Let's talk more about nursing.
“Turn up your hearing aid, Curmudge. I’m going to teach you more about nursing, and I don’t want you to miss anything.”
“Don’t you offer a senior discount, Jaded Julie, that will allow me to not hear 10% of your words? Well anyway, I recall from our discussion two weeks ago that when you were a new nurse you considered your profession a calling and your daily work a mission. Apparently your feelings have become tempered by the realities of experience. Tell me more.”
“Curmudge, hospital nursing is the ultimate ‘in-the-middle’ occupation. Despite being licensed professionals, we have an almost infinite number of bosses—each patient that we care for, his or her physician and the physician’s PA, and the hospital administration. Of course the heart of the job is to meet the needs of the patients:
· to experience minimal pain and discomfort,
· to receive the best possible treatment and care,
· to be kept safe from errors, infections, or falls,
· and, in general, to be delighted with their stay at an Affinity hospital.
While doing the above, we try to meet our own needs for professional and personal fulfillment. Nursing is always demanding and sometimes frustrating.”
“That’s an imposing list, Julie. Indeed, nurses are special people. When I meet a nurse in the stairway, I feel like saying, ‘Thank you.’ But as Lean zealots, you and I feel that in all of the above there are processes that contain waste and efforts that add no value from the patients’ or physicians’ perspective. With less waste, nursing would be more rewarding. Getting rid of this waste will be a big job. How will we do it?”
“You know better than that, Curmudge. It’s not going to be we; it’s going to be they, the nurses working in teams to 5S their areas and take waste out of their processes. Nurses excel in working on teams; think of how well they do in the OR or the ED when a trauma patient rolls in.”
“On the other hand, Lean practiced by nurses will be somewhat different from Lean in manufacturing. In manufacturing the workers gain a measure of participative management. But despite having many bosses, hospital nurses already enjoy significant professional autonomy. Their autonomy may be reduced by Lean when processes become more standardized and efficient.”
“Let’s put off autonomy and nursing practice issues for awhile, Curmudge. We need to score some early wins in areas that are not controversial. I believe you quality guys call that ‘picking the low-hanging fruit’. For example, if we train people in 5S and immediately put them to work using it, they will gain a feeling of accomplishment and be able to see the evidence of their good work. There aren’t many storage areas in the hospital that couldn’t profit from a good 5S’ing.”
“Not so fast, Julie. Before we do lots of rapid improvement events, or what my colleagues call ‘drive-by kaizens,’ we need to understand the ‘big picture’. As someone said, ‘Before the bus leaves, it must have a destination.’ Recall our discussions about hoshin kanri planning back in September and October of 2007. Then on January 18 we mentioned Pascal Dennis’s emphasis on strategy deployment to focus Lean tools on business needs. It’s important for people with discretionary time, as we discussed on 10/12/07, to work on hoshins and the projects that support them.”
“That’s not me, Curmudge. As a staff nurse, virtually all of my time is what you Lean folks call ready-to-serve. Is there some sort of big picture that guides the Lean efforts that I can squeeze into my ready-to-serve time?”
“I think so, Julie. I found a very insightful article that we’ll talk about next time. Although the paper is from France, it is written in English.”
“If it weren’t, Curmudge, you would find me taking ‘French leave’ from our discussion.”
“Au revoir, Julie.”
Affinity’s Kaizen Curmudgeon
“Don’t you offer a senior discount, Jaded Julie, that will allow me to not hear 10% of your words? Well anyway, I recall from our discussion two weeks ago that when you were a new nurse you considered your profession a calling and your daily work a mission. Apparently your feelings have become tempered by the realities of experience. Tell me more.”
“Curmudge, hospital nursing is the ultimate ‘in-the-middle’ occupation. Despite being licensed professionals, we have an almost infinite number of bosses—each patient that we care for, his or her physician and the physician’s PA, and the hospital administration. Of course the heart of the job is to meet the needs of the patients:
· to experience minimal pain and discomfort,
· to receive the best possible treatment and care,
· to be kept safe from errors, infections, or falls,
· and, in general, to be delighted with their stay at an Affinity hospital.
While doing the above, we try to meet our own needs for professional and personal fulfillment. Nursing is always demanding and sometimes frustrating.”
“That’s an imposing list, Julie. Indeed, nurses are special people. When I meet a nurse in the stairway, I feel like saying, ‘Thank you.’ But as Lean zealots, you and I feel that in all of the above there are processes that contain waste and efforts that add no value from the patients’ or physicians’ perspective. With less waste, nursing would be more rewarding. Getting rid of this waste will be a big job. How will we do it?”
“You know better than that, Curmudge. It’s not going to be we; it’s going to be they, the nurses working in teams to 5S their areas and take waste out of their processes. Nurses excel in working on teams; think of how well they do in the OR or the ED when a trauma patient rolls in.”
“On the other hand, Lean practiced by nurses will be somewhat different from Lean in manufacturing. In manufacturing the workers gain a measure of participative management. But despite having many bosses, hospital nurses already enjoy significant professional autonomy. Their autonomy may be reduced by Lean when processes become more standardized and efficient.”
“Let’s put off autonomy and nursing practice issues for awhile, Curmudge. We need to score some early wins in areas that are not controversial. I believe you quality guys call that ‘picking the low-hanging fruit’. For example, if we train people in 5S and immediately put them to work using it, they will gain a feeling of accomplishment and be able to see the evidence of their good work. There aren’t many storage areas in the hospital that couldn’t profit from a good 5S’ing.”
“Not so fast, Julie. Before we do lots of rapid improvement events, or what my colleagues call ‘drive-by kaizens,’ we need to understand the ‘big picture’. As someone said, ‘Before the bus leaves, it must have a destination.’ Recall our discussions about hoshin kanri planning back in September and October of 2007. Then on January 18 we mentioned Pascal Dennis’s emphasis on strategy deployment to focus Lean tools on business needs. It’s important for people with discretionary time, as we discussed on 10/12/07, to work on hoshins and the projects that support them.”
“That’s not me, Curmudge. As a staff nurse, virtually all of my time is what you Lean folks call ready-to-serve. Is there some sort of big picture that guides the Lean efforts that I can squeeze into my ready-to-serve time?”
“I think so, Julie. I found a very insightful article that we’ll talk about next time. Although the paper is from France, it is written in English.”
“If it weren’t, Curmudge, you would find me taking ‘French leave’ from our discussion.”
“Au revoir, Julie.”
Affinity’s Kaizen Curmudgeon
Thursday, July 10, 2008
Some people don't know about 5S.
“Curmudge, I’ve been reading your mind again.”
“Well if anybody can, it’s you, Jaded Julie.”
“If we are going to continue talking about nursing and Lean, at some point you’ll mention 5S. Some people don’t even know what 5S is.”
“Gosh, I must have forgotten to introduce it. But 5S is such a household word around Affinity, how could anyone be unacquainted with it?”
“It’s certainly not a household word in my household. Whenever I try to explain 5S to my husband, he gets up off the couch and leaves the room on the second S.”
“I sympathize; that happens in our house, too. So anyway, 5S is most easily understood when we envision its ultimate result: a place for everything, and everything in its place. 5S is needed because people—in fact, all of nature—exhibit a tendency toward disorder. The scientific term for this is entropy.”
“Hey, Curmudge! Please, no thermodynamics.”
“Okay, especially for you, we’ll name the scientific term Ross, my 20-month old grandson. Every night after Ross goes to bed, his dad puts all of his toys back in the toy box. By the end of the next day, the toys are scattered all over the house again. Why? Because Ross has been doing what comes naturally.”
“I get it. People in the hospital are a bit like Ross, and they have a tendency to put stuff down without returning it to its proper place. We use 5S to reverse the resulting disorder, and it can be applied to storage and supply areas, to desks, and virtually anywhere. So what, specifically, does ‘5S’ mean?”
“Like most of Lean, 5S is based on Japanese words—in this case, five of them. There are several English translations; here is one set:
· Sort. Keep what is needed, and get rid of what is not needed or almost never used.
· Straighten/Simplify/Set in order. A place for everything, and everything in its place.
· Scrub/Shine/Sweep. In health care, cleanliness is essential.
· Standardize. Make the organization of a room or drawer identical with that of all other rooms or drawers used for the same purpose. Also, make the first 3 S’s a standard.
· Sustain. Develop the self-discipline to make the first four S’s a habit and part of the organization’s culture.”
“The concepts are not so tough, Curmudge, but making it happen could be a challenge.”
“5S’ing a room or an area is usually a team event. Fortunately, the Kaizen Promotion Office has prepared a 5S Resource Guide that should help one organize a 5S activity.”
“It seems, Curmudge, that several aspects of Lean are not truly natural and have to be taught. Recall our discussion on May 8 about Leadership and Character.”
“Many people here at Affinity will need to learn 5S, which is somewhat unnatural, just as Ross has yet to encounter toilet training and putting away his toys.”
“It shouldn’t be a problem here, Curmudge. Our colleagues have all passed potty training, so 5S should be a slam-dunk.”
Affinity’s Kaizen Curmudgeon
“Well if anybody can, it’s you, Jaded Julie.”
“If we are going to continue talking about nursing and Lean, at some point you’ll mention 5S. Some people don’t even know what 5S is.”
“Gosh, I must have forgotten to introduce it. But 5S is such a household word around Affinity, how could anyone be unacquainted with it?”
“It’s certainly not a household word in my household. Whenever I try to explain 5S to my husband, he gets up off the couch and leaves the room on the second S.”
“I sympathize; that happens in our house, too. So anyway, 5S is most easily understood when we envision its ultimate result: a place for everything, and everything in its place. 5S is needed because people—in fact, all of nature—exhibit a tendency toward disorder. The scientific term for this is entropy.”
“Hey, Curmudge! Please, no thermodynamics.”
“Okay, especially for you, we’ll name the scientific term Ross, my 20-month old grandson. Every night after Ross goes to bed, his dad puts all of his toys back in the toy box. By the end of the next day, the toys are scattered all over the house again. Why? Because Ross has been doing what comes naturally.”
“I get it. People in the hospital are a bit like Ross, and they have a tendency to put stuff down without returning it to its proper place. We use 5S to reverse the resulting disorder, and it can be applied to storage and supply areas, to desks, and virtually anywhere. So what, specifically, does ‘5S’ mean?”
“Like most of Lean, 5S is based on Japanese words—in this case, five of them. There are several English translations; here is one set:
· Sort. Keep what is needed, and get rid of what is not needed or almost never used.
· Straighten/Simplify/Set in order. A place for everything, and everything in its place.
· Scrub/Shine/Sweep. In health care, cleanliness is essential.
· Standardize. Make the organization of a room or drawer identical with that of all other rooms or drawers used for the same purpose. Also, make the first 3 S’s a standard.
· Sustain. Develop the self-discipline to make the first four S’s a habit and part of the organization’s culture.”
“The concepts are not so tough, Curmudge, but making it happen could be a challenge.”
“5S’ing a room or an area is usually a team event. Fortunately, the Kaizen Promotion Office has prepared a 5S Resource Guide that should help one organize a 5S activity.”
“It seems, Curmudge, that several aspects of Lean are not truly natural and have to be taught. Recall our discussion on May 8 about Leadership and Character.”
“Many people here at Affinity will need to learn 5S, which is somewhat unnatural, just as Ross has yet to encounter toilet training and putting away his toys.”
“It shouldn’t be a problem here, Curmudge. Our colleagues have all passed potty training, so 5S should be a slam-dunk.”
Affinity’s Kaizen Curmudgeon
Thursday, July 3, 2008
Let's talk about nursing.
“Let’s talk about nurses and nursing, Jaded Julie. Nurses are my favorite people. This will be a giant leap from our recent discussions about difficult employees.”
“The last time we talked about nursing was back on December 3, 2007, when I told you about the nursing process. I thought you had forgotten all about us.”
“Me? Forget? Although I did sort of overlook my 50th wedding anniversary a few weeks ago.”
“Congratulations, Curmudge.”
“On my anniversary?”
“No. On surviving the forgetting of your anniversary.”
“Not a problem. To make up for it I sent my wife to Ireland, the land of her ancestors. So what do you want to teach me about nursing? As a nurse, you’ll have to provide the expertise for our discussion.”
“Naturally, Curmudge. If we had to depend on your nursing knowledge, our story would end right here. But more to the point, why am I going to teach you about nursing? I’ll bet that you are going to bend our conversation so that it relates to Lean. I’ll have to admit that applying Lean to nursing is likely to be quite different from implementing it in manufacturing.”
“You’ve got the right idea, Julie, as usual. Let’s start by characterizing the actors (usually actresses) in our scenario. Nurses clearly have some endearing as well as compelling professional qualities.”
“Of course we do. Let me count the ways. We are technically proficient, dedicated, compassionate, capable of hard work, sufficiently versatile to move into management or education, and charming in every way.”
“Hey, where did you get that ‘charming’ stuff, Julie? That wasn’t on my list.”
“Of course it wasn’t. I added it to describe me, Jaded Julie.”
“Well, if we are going to describe you, we’d better add feisty to the list. But that doesn‘t apply to all nurses. Is there anything else you’d like to add?”
“Back when I was starting out, I viewed my profession as a ‘calling’ and every day’s work a ‘mission.’ Hopefully most new nurses feel that way. However, as time passed my view of my profession hasn’t changed, but I’m not as starry-eyed about my daily work. I’ve seen too much waste and inefficiency. I guess I’ve just become jaded.”
“It’s interesting that you should choose that word, Julie. I sensed that you felt that way when we first met over a year ago. It may be the result of having to do too many ‘workarounds.’ I understand that nurses are the world’s best ‘workarounders’.”
“You’ve got that right, Curmudge. When I need something to care for a patient and the item isn’t where it’s supposed to be, I have to hunt for it. If I can’t find it, I devise a substitute or take a shortcut. These are all ‘workarounds,’ and shortcuts by some nurses might even compromise patient safety. Running down the hall to search for an urgently needed item may be good exercise for me, but it’s also one reason why older nurses migrate away from direct patient care.”
“If I were the patient, I’d prefer a workaround than having to do without something essential, but I surely don’t want to be the subject of an unsafe shortcut. It sounds to me as if the processes and procedures used by nurses would be ideal candidates for a Lean cultural transformation. If you did that, you could reduce your waste and inefficiency and minimize your workarounds.”
“You did it, Curmudge! Just as I expected, you sneaked Lean into our conversation. You are as predictable as you are forgetful.”
“Maybe so, Julie, but I didn’t forget that Lean is the reason for this blog’s existence. You might say that I worked our conversation around to Lean.”
“And my further prediction is that we are going to continue our discussion about Lean in nursing. Right?”
“Right, Nurse Charming.”
Affinity’s Kaizen Curmudgeon
“The last time we talked about nursing was back on December 3, 2007, when I told you about the nursing process. I thought you had forgotten all about us.”
“Me? Forget? Although I did sort of overlook my 50th wedding anniversary a few weeks ago.”
“Congratulations, Curmudge.”
“On my anniversary?”
“No. On surviving the forgetting of your anniversary.”
“Not a problem. To make up for it I sent my wife to Ireland, the land of her ancestors. So what do you want to teach me about nursing? As a nurse, you’ll have to provide the expertise for our discussion.”
“Naturally, Curmudge. If we had to depend on your nursing knowledge, our story would end right here. But more to the point, why am I going to teach you about nursing? I’ll bet that you are going to bend our conversation so that it relates to Lean. I’ll have to admit that applying Lean to nursing is likely to be quite different from implementing it in manufacturing.”
“You’ve got the right idea, Julie, as usual. Let’s start by characterizing the actors (usually actresses) in our scenario. Nurses clearly have some endearing as well as compelling professional qualities.”
“Of course we do. Let me count the ways. We are technically proficient, dedicated, compassionate, capable of hard work, sufficiently versatile to move into management or education, and charming in every way.”
“Hey, where did you get that ‘charming’ stuff, Julie? That wasn’t on my list.”
“Of course it wasn’t. I added it to describe me, Jaded Julie.”
“Well, if we are going to describe you, we’d better add feisty to the list. But that doesn‘t apply to all nurses. Is there anything else you’d like to add?”
“Back when I was starting out, I viewed my profession as a ‘calling’ and every day’s work a ‘mission.’ Hopefully most new nurses feel that way. However, as time passed my view of my profession hasn’t changed, but I’m not as starry-eyed about my daily work. I’ve seen too much waste and inefficiency. I guess I’ve just become jaded.”
“It’s interesting that you should choose that word, Julie. I sensed that you felt that way when we first met over a year ago. It may be the result of having to do too many ‘workarounds.’ I understand that nurses are the world’s best ‘workarounders’.”
“You’ve got that right, Curmudge. When I need something to care for a patient and the item isn’t where it’s supposed to be, I have to hunt for it. If I can’t find it, I devise a substitute or take a shortcut. These are all ‘workarounds,’ and shortcuts by some nurses might even compromise patient safety. Running down the hall to search for an urgently needed item may be good exercise for me, but it’s also one reason why older nurses migrate away from direct patient care.”
“If I were the patient, I’d prefer a workaround than having to do without something essential, but I surely don’t want to be the subject of an unsafe shortcut. It sounds to me as if the processes and procedures used by nurses would be ideal candidates for a Lean cultural transformation. If you did that, you could reduce your waste and inefficiency and minimize your workarounds.”
“You did it, Curmudge! Just as I expected, you sneaked Lean into our conversation. You are as predictable as you are forgetful.”
“Maybe so, Julie, but I didn’t forget that Lean is the reason for this blog’s existence. You might say that I worked our conversation around to Lean.”
“And my further prediction is that we are going to continue our discussion about Lean in nursing. Right?”
“Right, Nurse Charming.”
Affinity’s Kaizen Curmudgeon
Thursday, June 26, 2008
More about Difficult People
“Our discussion last time about your experience with difficult people was pretty depressing, Curmudge. Yet I expect that some businesses have even worse employees than you had.”
“That’s for sure, Jaded Julie. And sometimes the problem people aren’t your subordinates; they can be your colleagues and even your boss.”
“I shudder at the thought. What can I do?”
“You’re not alone, Julie. Get help from the experts in HR as I did, and keep your boss informed, unless she is the bad actor. There’s also a ton of books out there detailing how others approached their ‘people’ problems. Bell and Smith present their advice in a very short book*, and Solomon provides guidance on dealing with bosses, colleagues, and subordinates**. Here’s how each of these books categorizes difficult people:
· Bell and Smith: (1) the voice crying in the wilderness, (2) the backstabber, (3) the yes, but (4) the politician, (5) the busybody, (6) the short fuse, (7) the liar, (8) the blamer, (9) the bitter recluse, and (10) the silent martyr.
· Solomon: (1) hostile/angry, (2) pushy/presumptuous, (3) deceitful/underhanded, (4) shrewd/manipulative, (5) rude/abrasive, (6) egotistical/self-centered, (7) procrastinating/vacillating, (8) rigid/obstinate, (9) tight-lipped/taciturn, and (10) complaining/critical.”
“Wow, Curmudge! I didn’t know there could be so many types of painful people. I’ll really have to do my homework if I recognize any of these folks. Fortunately, there aren’t many of these types in the hospital, unless they are on the other side of the door in Behavioral Health.”
“In a Lean culture, I would consider the people listed by the authors as team-destroying or team-endangering. I hope that in the hospital the problems you’ll be faced with are less serious. Perhaps we can call them second-order difficult people. Here are some of the deficiencies that might be found among hospital staff: reluctance to help others, poor communication, absence of empathy, chronically late for work, resistance to change, poor technique, and carelessness. I’m sure you can make your own list that is much longer. Of course when patient safety is a concern—as in poor technique and carelessness—the problem is much more serious than second order.”
“So how do we tackle second-order problems, Curmudge? You taught me that reluctance to address a performance or behavioral issue is a failure in servant leadership.”
“It certainly is. Al Stubblefield (we mentioned his book on March 6) said, ‘You’ll never change what you tolerate.’ Quint Studer, whose book we referenced on January 14, recommended that a hospital—with employee participation—develop a set of standards of behavior. Stubblefield’s book has a partial example. Prospective employees must sign this as part of their application. Employees who cannot improve their attitude or performance in a way that meets the commitment that they signed may be asked to leave the organization. Of course before that point is reached, you should try to guide them toward doing better.”
“It sounds reasonable, Curmudge, but not especially easy. Do either of the authors have specific suggestions on how to proceed?”
“Here’s what Studer proposes we do in a meeting with a low performer:
· Do not start the meeting on a positive note.
· Describe the behavior you have seen.
· Evaluate how you feel about that behavior.
· Show how the work must be done (this may occur after the meeting).
· Make certain that the employee knows the consequences of continued poor performance.”
“It’s as you said a few weeks ago, Curmudge. ‘A servant leader can be just as demanding of her direct reports as anyone else.’ Sounds a lot like tough love.”
“That’s true, Julie. You’ve learned a lot, but I hope that you’ll never need to use it.”
“Oh, I’ll use it all right. I’m going to go home and write a set of standards of behavior for my husband. He’ll have to fix dinner for the kids when I work the p.m. shift, take me out for dinner once a week, watch only one football game per weekend, will not practice his bagpipes when I’m working the night shift and trying to sleep during the day, …”
Affinity’s Kaizen Curmudgeon
* Bell, A.H. and Smith, D.M. Winning With Difficult People. Barron’s, 1991.
** Solomon, M. Working With Difficult People. Prentice Hall, 1990. (Both books available in the Appleton Public Library.)
“That’s for sure, Jaded Julie. And sometimes the problem people aren’t your subordinates; they can be your colleagues and even your boss.”
“I shudder at the thought. What can I do?”
“You’re not alone, Julie. Get help from the experts in HR as I did, and keep your boss informed, unless she is the bad actor. There’s also a ton of books out there detailing how others approached their ‘people’ problems. Bell and Smith present their advice in a very short book*, and Solomon provides guidance on dealing with bosses, colleagues, and subordinates**. Here’s how each of these books categorizes difficult people:
· Bell and Smith: (1) the voice crying in the wilderness, (2) the backstabber, (3) the yes, but (4) the politician, (5) the busybody, (6) the short fuse, (7) the liar, (8) the blamer, (9) the bitter recluse, and (10) the silent martyr.
· Solomon: (1) hostile/angry, (2) pushy/presumptuous, (3) deceitful/underhanded, (4) shrewd/manipulative, (5) rude/abrasive, (6) egotistical/self-centered, (7) procrastinating/vacillating, (8) rigid/obstinate, (9) tight-lipped/taciturn, and (10) complaining/critical.”
“Wow, Curmudge! I didn’t know there could be so many types of painful people. I’ll really have to do my homework if I recognize any of these folks. Fortunately, there aren’t many of these types in the hospital, unless they are on the other side of the door in Behavioral Health.”
“In a Lean culture, I would consider the people listed by the authors as team-destroying or team-endangering. I hope that in the hospital the problems you’ll be faced with are less serious. Perhaps we can call them second-order difficult people. Here are some of the deficiencies that might be found among hospital staff: reluctance to help others, poor communication, absence of empathy, chronically late for work, resistance to change, poor technique, and carelessness. I’m sure you can make your own list that is much longer. Of course when patient safety is a concern—as in poor technique and carelessness—the problem is much more serious than second order.”
“So how do we tackle second-order problems, Curmudge? You taught me that reluctance to address a performance or behavioral issue is a failure in servant leadership.”
“It certainly is. Al Stubblefield (we mentioned his book on March 6) said, ‘You’ll never change what you tolerate.’ Quint Studer, whose book we referenced on January 14, recommended that a hospital—with employee participation—develop a set of standards of behavior. Stubblefield’s book has a partial example. Prospective employees must sign this as part of their application. Employees who cannot improve their attitude or performance in a way that meets the commitment that they signed may be asked to leave the organization. Of course before that point is reached, you should try to guide them toward doing better.”
“It sounds reasonable, Curmudge, but not especially easy. Do either of the authors have specific suggestions on how to proceed?”
“Here’s what Studer proposes we do in a meeting with a low performer:
· Do not start the meeting on a positive note.
· Describe the behavior you have seen.
· Evaluate how you feel about that behavior.
· Show how the work must be done (this may occur after the meeting).
· Make certain that the employee knows the consequences of continued poor performance.”
“It’s as you said a few weeks ago, Curmudge. ‘A servant leader can be just as demanding of her direct reports as anyone else.’ Sounds a lot like tough love.”
“That’s true, Julie. You’ve learned a lot, but I hope that you’ll never need to use it.”
“Oh, I’ll use it all right. I’m going to go home and write a set of standards of behavior for my husband. He’ll have to fix dinner for the kids when I work the p.m. shift, take me out for dinner once a week, watch only one football game per weekend, will not practice his bagpipes when I’m working the night shift and trying to sleep during the day, …”
Affinity’s Kaizen Curmudgeon
* Bell, A.H. and Smith, D.M. Winning With Difficult People. Barron’s, 1991.
** Solomon, M. Working With Difficult People. Prentice Hall, 1990. (Both books available in the Appleton Public Library.)
Thursday, June 19, 2008
What about difficult people?
“Becoming a manager/leader doesn’t sound so tough, Curmudge. According to our recent discussions, I just have to be a humanist with technical competence and organizational smarts. But you said weeks ago that there might be 10% of the people out there who would resist change, wouldn’t want me to succeed, and would be just plain ornery.”
“The subject is difficult people, Jaded Julie, and there are courses offered and whole books written about how to deal with them. However, no matter how much their manager/leader has learned, she is in an unenviable position.”
“Why do people act that way, Curmudge?”
“I guess it’s like we talked about on May 8. Their mothers helped them with potty training, but they forgot to teach them how to be nice.”
“Did you ever have to deal with people like that?”
“I sure did, Julie. I had just joined the company and had been appointed lab manager. Within a short time I leaned that one team member ‘would but couldn’t’, one ‘could but wouldn’t’, and one hated several of the other team members. In fact she told them so to their face screaming with language that would make a drill sergeant blush. It was, to say the least, a turbulent staff meeting.”
“So what did you do?”
“The books would advise firing the lot of them, but there were some extenuating circumstances. Two of the ‘bad actors’ were looking for an excuse to sue the company for discrimination, and the company had deep pockets and didn’t want to be sued. So I worked closely with the local HR person and kept my boss—located in another state—apprised of the situation. Everyone else in the building, unless they were hard of hearing, knew all about it.”
“What about the guy that ‘would but couldn’t’? It sounds as if his issue was performance rather than behavior.”
“He was a great person, so we worked with him—and documented our efforts—for a full year. Ultimately he was terminated. It was very sad. We documented every conversation with the other two as well, and we required participation in the Employee Assistance Program. The whole process was like walking on eggs.”
“How was the lab’s performance during this period, Curmudge?”
“Surprisingly, it was quite good. There were other, excellent people in the lab, and even the problem people didn’t do too badly. Of course, I had to check their work very carefully; it made for some very long days. Things were better when we could keep everyone focused on their work and not on personalities.”
“So how did this end?”
“The company was consolidating their laboratories, and they closed ours. Some of our people retired, and the problem people went elsewhere. Perhaps they—but not their bosses—lived happily ever after. I was transferred back to the Midwest.”
“Golly, Curmudge, your hair is white, your beard is grey, your back is bent, and you walk rather slowly. Other than that, you don’t show much wear and tear from your experience with those people.”
“Right, Julie. But the problem is that I’m only 39 years old*.”
Affinity’s Kaizen Curmudgeon
*Of course, the Curmudgeon is kidding about his age.
“The subject is difficult people, Jaded Julie, and there are courses offered and whole books written about how to deal with them. However, no matter how much their manager/leader has learned, she is in an unenviable position.”
“Why do people act that way, Curmudge?”
“I guess it’s like we talked about on May 8. Their mothers helped them with potty training, but they forgot to teach them how to be nice.”
“Did you ever have to deal with people like that?”
“I sure did, Julie. I had just joined the company and had been appointed lab manager. Within a short time I leaned that one team member ‘would but couldn’t’, one ‘could but wouldn’t’, and one hated several of the other team members. In fact she told them so to their face screaming with language that would make a drill sergeant blush. It was, to say the least, a turbulent staff meeting.”
“So what did you do?”
“The books would advise firing the lot of them, but there were some extenuating circumstances. Two of the ‘bad actors’ were looking for an excuse to sue the company for discrimination, and the company had deep pockets and didn’t want to be sued. So I worked closely with the local HR person and kept my boss—located in another state—apprised of the situation. Everyone else in the building, unless they were hard of hearing, knew all about it.”
“What about the guy that ‘would but couldn’t’? It sounds as if his issue was performance rather than behavior.”
“He was a great person, so we worked with him—and documented our efforts—for a full year. Ultimately he was terminated. It was very sad. We documented every conversation with the other two as well, and we required participation in the Employee Assistance Program. The whole process was like walking on eggs.”
“How was the lab’s performance during this period, Curmudge?”
“Surprisingly, it was quite good. There were other, excellent people in the lab, and even the problem people didn’t do too badly. Of course, I had to check their work very carefully; it made for some very long days. Things were better when we could keep everyone focused on their work and not on personalities.”
“So how did this end?”
“The company was consolidating their laboratories, and they closed ours. Some of our people retired, and the problem people went elsewhere. Perhaps they—but not their bosses—lived happily ever after. I was transferred back to the Midwest.”
“Golly, Curmudge, your hair is white, your beard is grey, your back is bent, and you walk rather slowly. Other than that, you don’t show much wear and tear from your experience with those people.”
“Right, Julie. But the problem is that I’m only 39 years old*.”
Affinity’s Kaizen Curmudgeon
*Of course, the Curmudgeon is kidding about his age.
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