You may have read or seen reports about the poor conditions for injured soldiers at Walter Reed Hospital in DC. A good summary of the sad tale can be found here.
The article I’ve linked to looks at some of the management failings in the system.I’ll call the military leaders “management” since that’s the term we’re familiar with in the manufacturing world, as I think there are general leadership lessons that can be learned from this case.
Flayed by lawmakers’ criticism, Army leaders said Monday they accept responsibility for substandard conditions at the service’s flagship Walter Reed Army Medical Center but also said they hadn’t known about most of the problems.
Accepting responsibility is a good thing.Being unaware of bad conditions in your organization is miserable excuse.It’s not an excuse, whether you are a plant manager who is “unaware” of unsafe working conditions or products your plant is shipping that do not meet customer quality requirements.Lean teaches us to “go see” (the concept of “genchi genbutsu).
In addition to going to see, we must create an organization that is free of fear, so that problems we do not see (or cannot see) are brought to our attention by those who can see.Deming taught us that we need to eliminate fear in our organizations in order to improve quality.Are your employees afraid that bringing an issue to your attention will get them yelled at or singled out as a “troublemaker?”This human dynamic is seen in manufacturing, healthcare (nurses are afraid to raise issues for fear of retaliation by powerful surgeons), and I would suppose the dynamic is true in military situations with poor leadership.
I assume many leaders are afraid of the lean “genchi genbutsu” concept because they are afraid of what they might see.Seeing problems means that you have an obligation to fix them.How sad that many leaders feel a compulsion to play ostrich and stick their heads in the sand.
“I’m afraid this is just the tip of the iceberg, that when we got out into the field we may find more of this,” said Rep. Tom Davis, R-Va., a member of the House Oversight and Government Reform subcommittee that held the session.
“My question is, where have you been?” Rep. John Tierney, D-Mass., chairman of the panel, asked Army Undersecretary Peter Geren, Army Chief of Staff Gen. Peter Schoomaker and Vice Chief Gen. Richard Cody.
The leaders had their heads in the sand.
VP Dick Cheney promised action and response:
“There will be no excuses, only action,” Cheney told a gathering of the Veterans of Foreign Wars. “And the federal bureaucracy will not slow that action down.”
Unfortunately, I hear different reports from a good college friend who is a physician at Walter Reed.In an email to friends, he wrote, in part:
“The adminstrative oversight review ordered into military medical centers has already in less than 5 days created an additional mountain of beauracratic paperwork, meetings, outside reviews, and productivity reports (think TPS report cover sheets) to be generated by us medical staff. This will further detract from time that could be better spent doing patient care.”
This is not good. When we go to the “gemba” (the actual place) and observe problems, we have to work on fixing the underlying root cause of the problem.We cannot add extra layers of inspection in place of preventing problems from occurring in the first place.Added bureaucracy is a wasteful approach to eliminating waste.
Lawmakers listened as several patients testified with stories of lax or poor treatment at Walter Reed. Staff Sgt. John Daniel Shannon, who lost his left eye and suffered traumatic brain injuries from a rifle wound, said that after he was discharged from Walter Reed, he was given a map of the grounds and eventually found his way to outpatient quarters by wandering around and asking for directions. Then, he says, he “sat in my room for a couple of weeks wondering when someone would contact” him about continuing treatment.
How sad that the leadership wasn’t putting themselves in the shoes of their patients, their customers.How sad that traditional management approaches so often win out over lean thinking.Problems are hidden or ignored, and then when they arise, we claim we “didn’t know” and add extra waste on top of the waste.We need to do better, for the sake of the soldiers and for the sake of the doctors and other health providers. This isn’t a medical problem. This is a leadership problem.
What problems are hiding beneath the surface of YOUR organization?
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