I was asked a question by a Twitter follower over the weekend:
“What are the pros & cons of using direct observations in hospital environment to identify value & none value adding activities?”
It’s a short question, but I didn’t think I could answer it in 140 characters. So here goes (and please add your thoughts in the comments section).
There are many advantages of “going to the gemba” to observe (gemba being a Japanese word that means “the actual place” or, basically, the place where work is done).
As I wrote, in part, in my book Lean Hospitals:
How Do We Find Waste? Go and See
Once we know the definitions of waste, we have to take action. We have to “go and see” (genchi genbutsu, in Japanese), as Toyota would tell us. Ohno was famous for training engineers and managers to look for waste by drawing what came to be known as an “Ohno circle” on the floor, with chalk. The trainee was told to stand in the circle (just a few feet in diameter) and watch the process for hours, looking for waste. That is an extreme method and not one that is commonly used, but there are lessons to be drawn from it. First, you have to go and see with your own eyes, as meeting in a conference room to discuss the process is not as effective. Leaders at all levels have to go to the gemba to see what really happens.
In any organization, including hospitals, there are three forms of any process:
1. What the process really is
2. What we think the process is
3. What the process should be
Leaders cannot rely exclusively on reports, data, or metrics, especially early in the Lean journey. You might ask, “How long are patients waiting in the ED before seeing a doctor?” The hospital might already have measures and reports in place, but the most effective way to actually improve the process is to go and see for yourself to identify waste. This takes time, but that time will prove to be an extremely good investment for you and your team.
Some of the advantages of going to the workplace include:
- Seeing REALITY rather than relying on what people say about their work
- Building trust with employees, as they see that you see the problems they are facing (and are not blaming them for the waste)
- The opportunity to get staff feedback and patient feedback about what could or should be done better
- Making sure the definition of “value” is aligned to customer / patient needs
Some of the disadvantages of observing in the workplace might include:
- If there’s not trust, employees might feel “watched” or “policed”
- In circumstances like that, employees might not do their work as they normally would (they might be nervous and make mistakes or they might do everything exactly by the letter of the process, when they might normally be more casual about their work)
- It might be awkward or uncomfortable to observe when patients are present
- When you observe you might see a limited snapshot of time (hearing things like “it’s normally way busier than this” might tip you off)
All of those “con’s” or disadvantages can be addressed.
If trust does not exist, then managers should first spend time in the gemba building relationships and talking with staff. Orient the discussion around “how can I help you?” instead of seeming judgmental about waste. Even if you’re not being judgmental, pointing out the waste (and thinking of it as a systems/processes issue) will still lead to staff blaming themselves and therefore feeling criticized.
If we’re going to be observing when patients are present, we can go out of our way to introduce ourselves to patients and let them understand why the observation (and improvement work) is taking place. You might have a patient say something funny, as happened to me and a team once. You can hang signs that inform people who enter the department that workplace observation is taking place (with the goals including quality improvement, waiting time reduction, etc.). Most patients are happy to see this happening, trust me.
You might decide to stay out of the exam room, leaving that to be a private moment between the patient and clinicians. There’s so much waste in healthcare, we’re generally not trying to start out by making the clinical encounter more efficient. We’re looking for ways to prevent delays so the patient can get to the room more quickly, for example.
The way to address the “limited snapshot” problem is to observe at different times of the day and week… I always recommend to keep observing until you don’t see anything really new. There will be diminishing returns to the observation and “how long you should observe” and “how many times you should observe” depends on the situation and circumstances.
As I talk about in the book, we can observe with one of two different lenses:
- “Activity of the Patient” (or “Product,” more generally like a tube of blood)”
- “Activity of the Operator” (the people doing the work)
Some other thoughts from Chapter 4 of my book:
Observers should strive to build rapport with the employee and allow the employee to concentrate on performing high-quality work. If the observer sees an error or mistake being made that would impact a patient, the observer has a responsibility to help the employee (and patient) by saying something about the error. Employees who have done the actual work should conduct activity of the employee observations, making it a peer-to-peer interaction. If outsiders or supervisors do the observation, employees might be more nervous about negative outcomes, or clinicians might be understandably upset if engineering interns are timing how long they are in the restroom. Staff members at any level deserve to be involved as a partner in this observation and improvement – to be a scientist, not merely a subject.
Additionally, having coworkers observe work will lead to more accurate analysis and identification of waste. They are also more likely to know when observed employees are using methods that are inconsistent with others or standard practices. This realization serves as the first step in determining what the best work method should be. The observation and analysis can also uncover activities that certain roles should not be doing.
I think it’s a key point to have coworkers do observation. It can’t be just managers or consultants, for a number of reasons.
What are some of your tips and lessons learned?
About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as the new Executive Guide to Healthcare Kaizen. Mark is also the VP of Innovation and Improvement Services for KaiNexus.