How a Non-Lean Culture Can Harm Patients

Sometimes people ask me, "how does Lean apply in a hospital?" The critical issues in a hospital are more often about culture and environment (although using technical lean methods for improving processes and flow are important also).

Many hospitals, unfortunately, have "current state" cultures where people (particularly nurses or technologists) are afraid to speak up in the name of safety or quality. They are often afraid to speak up because they're intimidated by administrators or physicians or surgeons.

If somebody knows something unsafe has happened or is about to happen, they might keep quiet because:

1. They are too busy to speak up
2. They are too scared to speak up
3. Speaking up didn't get anything fixed last time, it just brought them grief, so why bother

This reminds me of my time in the GM factory, circa 1995. There was nothing "lean" about that environment (until we got new leadership).

It's sad that hospitals are often this way. The employees deserve better and patients certainly deserve better.

The Lean approach and the Toyota Way philosophy are very different than this. People are supposed to speak up, to "stop the line" when there is a quality or safety concern. Thankfully some hospitals are working on improving this culture (like Virginia Mason and ThedaCare).

Tracing this back to Deming, employees are supposed to be able to have pride in their work. Not letting them speak up, knowing something bad might happen destroys that. It's also not very customer/patient focused. As Deming said, we have to eliminate fear from the workplace if we want quality, and that includes hospitals. Especially hospitals. It requires leadership. People preaching about "this is what a lean culture should be" won't be enough.

I'm curious to read more about the aviation concept of "Crew Resource Management" and how it is being applied in medicine. Many airline crashes were traced back to a root cause of subordinates not being willing to question or challenge the pilot who was "in command" and infallible. But guess what, pilots (and doctors) are human and therefore fallible. It seems intuitive that applying CRM methods and coaching could potentially help change hospital or O.R. cultures (if people are willing to admit there's a problem with the current culture). Physician, heal thyself, eh?.

Subscribe via RSS | Lean Blog Main Page | Podcast | Message Board

Can Hiding Mistakes Help Your Career in Some Companies?

Cubicle Culture - WSJ.com: Why Learn and Grow On the Job? It's Easier To Feign Infallibility

Free Version via CareerJournal.com

In the Lean / Toyota Way mindset, we have the belief that we have to be open about our problems instead of hiding them, working around them, or covering them up. "No problems is a problem," as the Toyota expression goes. Instead of blaming people, we're supposed to look for systemic causes that can be prevented in the future.

But, do we have to be careful with being open about problems (and our role in them) if we're not in a Toyota-like organization? This WSJ article says we might have to be cautious with this, as it gives examples of those who get ahead by never admitting they are wrong.

At work, some people just won't admit to making a mistake. They have a gripping fear that it will indict their character, attract more work and invite future blame -- not to mention ruin a perfect record of never having admitted to one before.

To excel at never admitting mistakes, you have to take care to burnish your unaccountability and sorrylessness. It helps, for example, to have a fall guy, someone who has responsibility for a project who is less known to your boss than you are. Also, any mistake made under time pressure can be blamed on a lack of time. Soon enough, you'll combine elements, blaming the lack of time you had because of the sluggishness of the fall guy.

The article continues:

Flub artists sometimes get their just desserts. But in too many companies, nothing ever catches up with them. In fact, they seem to thrive, not in spite of their ability to avoid accountability but because of it.

The article compares two types of people:

In the business world and elsewhere, people either have a healthy belief in growth, whereby they expect to evolve their talents over time, or they possess a fixed mindset, whereby they believe their talents are innate traits that will carry them to the top.

So the Toyota method wants and encourages the latter, those who believe the grow and develop over time... what does your company value? What types of behavior does your company promote? The article gives a pretty disturbing example of some company cultures that reward "never apologizing," suggesting that companies with the "fixed mindset" lead people to:

"wallow in your success and disown your failures rather than rectify them, which is what the growth-mindset people did." Another study showed we can adopt a company's "fixed mindset" culture faster than you can say, "Sheep."

Subscribe via RSS | Lean Blog Main Page | Podcast | Message Board

"Toyota Culture" is Out

Jeffrey Liker's new book on Toyota Culture: The Heart and Soul of the Toyota Way is out. I'm getting a copy on Tuesday and hope to post a review ASAP. If anyone else is reading it, feel free to share comments here.

Update: I am recording a podcast interview with Dr. Liker on January 27. If you have questions for him, email me, or call the Lean Line to record an audio question. You can catch earlier discussions with him here and here.

Maybe this should be "culture week" here on the blog. On Tuesday, I'm attending the Lean Enterprise Institute class on "Creating a Sustainable Lean Culture" here in Dallas (anyone else attending???)

If anyone has stories to share about your own "lean culture" efforts, post a comment or email me using the link in left-hand column. Anything emailed to me will only be published with your express permission and I'll respect any needs for anonymity. Are you successfully transitioning to a "lean culture?" What are you struggling with?

I've been fortunate to be working one hospital laboratory department, in particular, that is doing some really good work toward becoming more lean in their management approach and culture (kaizen, problem solving, and other lean methods). Maybe I can ask their director to share some thoughts on their experiences. Lots of good work going on in other hospitals too, that's very encouraging.

Subscribe via RSS Lean Blog Main Page Podcast Message Board

L.A.M.E.: Not Involving Key Stakeholders

Got this story during an email exchange, used with express permission:

-----------------------------

I saw my doctor yesterday and told him I was doing a lean publication, and he immediately started complaining about well-intended but impractical top-down measures being taken in the name of lean, there at [major university] Health System. Interesting.

The example he gave me was a new form for requesting a test from the radiology lab. He pulled out both the old and new forms for me: the old form was short, with two spaces on it: one for the physician write in the name of the test he or she wants done, and a second space to write the reason for the test. The new form is physically much larger and ostensibly lists all the relevant tests; the physician just checks off the one needed. However, none of the choices include nuclear medicine-related tests, and there is no choice of “other,” where such a test could be written in. (I’m not familiar with the terminology.)

When asked why those tests were not included, the response was that the form would be too complicated. So, from my doctor’s point of view, a form that was simple at his end, and that allowed him to name whatever tests he needed, including the nuclear medicine tests, has been replaced with a form that is less flexible. Because, he opined, some small group at the main hospital decided that the new form would be an improvement. Obviously, this isn’t how lean is supposed to work: my doc feels totally disconnected from the process of making improvements and feels imposed upon from above. The whole exchange between my doctor and I on this was probably under two minutes: the main topic was rotator cuff tendinitis.

-------------------------

This is a shame. Lean improvements aren't something that should be imposed "top down." We have to work to get input from those actually working in the system. Experts can't be expected to design perfect processes or Standard Work the first time through, without input from people. This is true if it's assembly workers, medical technologists, or physicians. The newly designed form should have been considered a "first draft" that should have then accepted input from the doctors. If the form needed an "other" category, that input should have been accepted, it seems reasonable enough. It seems like an important item was left out in the name of standardization and intended improvement.

It's a shame that some hospitals are making the same mistakes that some factories made -- having "Lean" improvements antagonize the value-added workers instead of being something that helps them do their jobs in an easier way. If Lean isn't helping people, it 's going to give Lean a bad name and it might just be Lean As Mistakenly Executed.

Do you "Embrace your Misses?"

Another great thought from David Mann this week was highlighting how a Lean culture will "embrace it's misses" rather than try to cover them up.

His example was in the context of a production line not making it's production goal for a 30-minute time frame. Do you make excuses for why it didn't happen or do you consider the "miss" an opportunity to fix a problem?

We had a similar discussion in the context of using "near misses" to drive process improvement. I posed the example of how a nurse might catch, at the last minute, the error that the wrong drug (or wrong dosage) was nearly administered to a patient. I asked, "Do you hide that error or do you embrace that and figure out how things could have gotten that far? Sure, you caught the error next time, but what if you're not so lucky the next time?" We need to fix the root cause problems that led to the error and the near miss so we can avoid future near misses or future negative outcomes.

An experienced healthcare person in the room pointed out, "Many nurses would look at that scenario and say 'see, the system worked, we caught the error."

We have to re-train ourselves to realize that a "process error" is anything that goes wrong and could have been prevented, not just an error that causes harm to somebody.