Management’s Job is to be Proactive


Running a hospital: Our Joint Commission Report

The headline is my modification of a Deming expression, that management's job is prediction. Statistical process control was one way of predicting future outcomes of a process (if you have a statistically stable process, you can predict that tomorrow will be like today). Management also has to be proactive in terms of anticipating potential quality or safety problems. That's one reason management must go to the “gemba” (or “actual place”) and it's a reason why they must audit standard work and safety practices on a regular basis.

The blog I've linked to above is an interesting one, written by Paul Levy, the CEO of a major Boston Hospital (Beth Israel Deaconess Medical Center). He's very open in his discussion of hospital management issues, which is very admirable and unique. In the linked post, he writes about the hospital's recent “Joint Commission” inspection and links to the full report. Again, very admirable. I'm not sure if any other hospitals are doing this. Levy and BIDMC obviously mean well and want to improve their quality and their accountability to the public. Again, hooray for that.

Since many of you reading this are from the manufacturing world, I think the best parallel to the Joint Commission is to think about ISO9000, a quality “certification” of sorts that's been mocked in the Dilbert cartoon. The problem with ISO9000 is that getting certified is often NOT a predictor of good quality. That's not just me saying that, although my own personal experience bears that out. ‘A factory can document poor processes and still get certified if they follow those processes and still have poor quality. Expected future LeanBlog Podcast guest John Seddon wrote a whole book debunking ISO9000.

The Joint Commission has its critics also, as this story about Mass General Hospital (also in Boston) shows. Inspectors found numerous quality and safety problems, yet the hospital was still going to have its certification renewed. Quality and procedural problems included:

“…staff neglecting to wash their hands before and after caring for patients; medical records lacking dates and times; and patients on pain medication for whom caregivers had not recorded whether their pain had improved.

Why beat up on MGH for a problem that plagues most hospitals (poor handwashing, something I've written about before and something David Mann commented on)? Ok, sorry, that was sarcasm. What does the Joint Commission prize guarantee to you, the patient? It's not a guarantee that caregivers are going to wash their hands!!! Maybe it's a certification that says they're trying hard or that they care, but that's not enough.

There's more criticism of the Joint Commission in the August 6 issue of “Modern Healthcare” magazine. John Toussaint, CEO of ThedaCare, a leading example of Lean healthcare, criticized them by saying:

“… the Joint Commission's hospital accreditation criteria falls short of what's needed to ensure safe, quality healthcare.”

So back to BIDMC, what problems were found in their Joint Commission report?

Problems included:

Doctors were not following standard work (my term, not theirs) and irregularly used the hospital's “medication reconciliation” system. That system helps avoid drug interaction and allergy problems. Levy said, “Over the coming weeks and months, we will make use of the system mandatory.” You might think, why not now, this week, today? Why not before? I'm sure people at BIDMC knew the system wasn't be used, why wasn't this fixed? As Levy pointed out in the comments, it is a complication that physicians are not employees, but that's no excuse — it's just an additional difficult leadership challenge, not being able to rely on “being the boss.” Toyota's Gary Convis was always quoted as being taught you should “lead as if you have no authority.” Maybe Convis can run a hospital now that he's retired from Toyota?

“Code carts” in the patient units didn't have proper security for certain medication. “We are fixing this,” Levy says. Again, did this require outside inspectors to discover? It seems reasonable that a hospital would consider drug security to be an important issue. Why was it not proactively addressed? Levy commented that they did have audits and “hold managers accountable,” but that's not the same as actually fixing it, is it?

In another safety problem, Levy reported, “…some gas canisters were not properly secured. This is a true public safety hazard. If an unsecured gas canister falls and the regulator breaks off, the heavy tube can be an uncontrolled projectile.” To those of you working in factories — how often is this unsafe condition allowed to exist? Hospital administrators and managers need to be in the “gemba” auditing for situations like that. Oh, and the gaps in the fire doors were too wide. Oops, they'll fix that too, now that it was pointed out. Levy said that it's hard to find a large factory that wouldn't have that problem. Really? If so, is that an excuse?

Levy says this:

“The upshot is this. We did very, very well. On average, the Joint Commission finds 10 or more requirements for improvement in their hospital surveys. We had eight. Our re-accreditation is secure. The areas in which they found us wanting were legitimate and proper, and it is our job to fix them. The good news is that we were not surprised. Most of the areas they pointed out were on our agenda to fix over the coming months as part of our continuous improvement efforts.”

Being “on the agenda” is not the same is being fixed! I know that we can't magically fix all problems at the drop of a hat, but all organizations need to prioritize safety and quality issues, be proactive, and prioritize things. Is it complacency that thinks, “these things have been a problem for a long time, so we can take our time in fixing them?” Maybe it's a pat on the back to the employees to say “we did very, very well” but I'd rather see the Toyota mindset of striving for perfection and not being satisfied with passing marks from the Joint Commission.

I know I'm beating up on them, and I'm sure the hospital and its leadership have the best intentions. But, given the state of healthcare quality and safety, intentions aren't enough. We need improvement! Again, I do admire the hospital and Levy opening themselves open to criticism from yahoos like me.

I did submit a question to Levy on his blog (if you haven't figured that out already) and we had some discussion, you can read it yourself in his comments section or see Kevin's post about it on Evolving Excellence. I won't rehash it all here, but it's too bad that Paul started using the “tired excuse” (as another commenter said) that patients are complex. Of course they are, but let's discuss how to fix these problems faster rather than debating whose environment is more complicated. 600,000 unique patients don't require 600,000 unique processes to support their care. I'm not talking about standardizing how doctors diagnosis and cure. I'm talking about standardizing the truly repeatable support processes (lab, pharmacy, radiology, etc.). There aren't 600,000 femurs so different as to require 600,000 different ways to x-ray or MRI them.

Please do visit Paul's blog and read his full post and all of the comments. Thoughts?

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. Mark, tried to post this on the other site, but their less-than-perfect spam filter wouldn’t let me. Would you please post it for me? Here it is:

    You folks take offense and get defensive pretty easily. Please read the rest of the dialogue on that posting, and you will see that we agree a lot. I never said what you do is easy. I just said it is different in some important ways. If you don’t recognize the differences, you are bound to fail in applying knowledge from other industries.

    Also, please read an earlier posting that I did on applying LEAN principles in the hospital. Yes, duh, it includes quality. And, employee satisfaction.

    And, I am actually not a medical professional. All of my professional experience before this job is in other industries.

    But I have learned this. Next time you or a loved one are in a hospital as a patient, just try to think of all human beings as a single product. I absolutely guarantee you will have a different view when you or s/he are a patient in a bed.

  2. Paul – thanks for reading and commenting. I know we’re ultimately working toward the same goals here, so I agree we should focus on the common ground rather than nitpicking or sniping across industries.

    I think you were the one who got defensive and said “we’re complex.” I wish we weren’t debating the complexity issue. The real issue (and the thing I take offense to) is that hospital quality systems are (broad generalization here) so poor. Complexity in our patients (or, for factories, complexity in manufactured products) isn’t an excuse for having overly complex or non-existent processes. Making complex toys isn’t an excuse for using lead paint. Bringing up complexity and the differences in our industries is a red herring.

    I think that you’re creating the distraction that gets us away from the real issues I was trying to raise — why aren’t these known problems fixed sooner rather than later? How do we get more effective management systems in hospitals so that patients and employees aren’t burdened or harmed while we’re waiting for fixes?

    I don’t mean to be singling out you or your hospital. But, having a blog opens you up to that. I’m trying not to be unfair here. The fact that we’re all unique as human beings isn’t an excuse for each lab result to be processed differently or each person entering your room deciding to be “unique” about washing or not washing their hands. We can be emotional about our patients, but we have to be process focused and rational when looking at all of the support processes that allow us to take care of patients. There’s no good excuse for the amount of process variation in hospitals (again, very generally speaking). It’s just a historical lack of focus on that and healthcare is catching up. I’m glad you’re letting “outsiders” like me help (and I recognize you’re an outsider too… again, more common ground).

    I’ll look for the other post about Lean and I’ll link to it. I know it’s “duh” that Lean includes quality, but so many organizations (in manufacturing AND healthcare) miss that point and use Lean to antagonize or lay off employees. I can’t assume everyone understands Lean is about quality.

    My email link is on here if you’d like to take the discussion private. I’m trying to be constructive and raise important issues. I get fired up about poor healthcare quality exactly because I *do* care about patients, whether its me, my family, or total strangers. As outsiders, we’re blessed with not being burdened by “it’s always been this way” or “these problems are bound to happen” thinking.

    Nobody deserves to have their lab results mixed up, to get the wrong drugs, or to wait in the ER too long before getting a bed. Let’s quit making excuses and fighting and get back to fixing these problems. That’s my hope. Why aren’t these problems being fixed faster? I think the Lean approach can help (and IS helping in many hospitals around the world).

    Those of us who are being successful with it DO realize that healthcare is different. But, at some level, hospitals are people doing work, with others trying to manage them. Many of the dysfunctions that Lean tries to solve (such as the old approach of managers trying to tell employees what to do, as a commenter discussed on your blog post) are universal and human nature.

  3. No offense guys… but to Paul, why aren’t you spending more time leading your hospital instead of writing about leading it? I don’t know if any of this discussion really helps anything, does it? More work, less talk!

  4. Neutron jerk,

    Exchanging information does help. Please don’t discount it.


    Enough back and forth. We are getting repetitive and boring for others. I’m not making excuses or getting defensive. I am explaining fundamental differences in our organization from many others. As mentioned, we are using LEAN where we think it can help. We are also using other approaches where we think they might fit in better with the peculiar culture of an academic medical center.

  5. Paul – OK, since you’re back here, this isn’t boring at all! I don’t think we often have a CEO posting on here. What’s boring and repetitive is you repeating the same stuff, that we’re different and complex.

    What about the questions at hand? How can hospital be more proactive in solving and preventing serious safety problems? How do you prioritize improvements, how do you hold people accountable? More importantly, do you look at the system instead of placing blame on “accountable” managers?

    Do you agree with what the Thedcare CEO says about the Joint Commission?

    How will your hospital in a better position the next time they come around?

    It would be productive and not boring if you could address questions like that instead of diversions like “we’re different.” We’ll grant you that, now please stop belaboring that point. I see more substantive discussion out of Mark, he’s not repeating the same “back and forth.”

  6. Sorry, no time for more here. Read many posts on my blog to see other stuff we are doing: Check, in particular, the posts entitled “What Works” during the last several months. Also, read “Change must come from within” for a sense of the culture of an academic medical center.

  7. Too bad, it was nice having you here Paul.

    I’ll give the guy and break and point out what he said NICE about manufacturing (quit being so defensive, ya whiners):

    “I am more familiar with other industries, in which the expectations are different and the understanding of systemic quality improvement is much more advanced.”

    He means manufacturing. Our systemic quality improvement is something to be proud of, when it’s done well.

  8. This whole concept of “doctors aren’t our employees so we can’t tell them what to do” is mindboggling. Can’t you rally them around what’s best for the patients and their care? How did things devolve to the point where MD’s won’t use systems that are put in place? Is it a lack of training? Lack of understanding? Lack of leadership? I’d hate to just blame the MD’s for being stubborn.

    As an outsider, it really stinks to hear stuff like that about the “inside” of a hospital.

  9. I’m baffled by the ‘doctors aren’t employees’ as well. I’ve seen this come up on Marks blog many times.

    I would hate generalize as to personality types of doctors, the medical system itself, insurance companies etc.

    The bottom line is if they work in a hospital aren’t they accountable to that hospital even as independent contractors? Does this all point back to hospital leadership?

    Even if a doctor has a unique set of skill should they be allowed to work around a system based on the patients safety?

  10. The dysfunctional explanation I’ve often read about is hospitals view doctors as a source of revenue (MD’s bring in patients), so the hospitals treat them with kid gloves, because an offended doctor starts taking their patients to another hospital, maybe with lower standards.

    Imagine if your “simple” factory had assembly line workers who brought in car buyers. Could you hold the guy installing the windshield accountable if making him mad meant lost car sales, because he’d jump from GM to Ford?

    Crazy, huh?

    That kind of stuff wasn’t in the movie Sicko, but it makes me want to suggest a sequel.

  11. Hi, I’m back again. The last few anonymous comments suggest that some of you, who are obviously expert in process improvement, have missed a key factor about process improvement: You need to understand the underlying culture and structure in the organization.

    When you ask a question like this — “Even if a doctor has a unique set of skill should they be allowed to work around a system based on the patients safety?” — you are showing a high level of naivete or lack of understanding.

    What I have been trying to say here and what I have written about on my blog is that the organization of an academic medical center is qualitatively different from any other business I have ever seen. The issue is not that the doctors don’t care about patient safety, and it is not about their being greedy — it is that medicine has never been built around the idea of systemic improvement. Instead, it is a cottage industry, in which each provider has been trained for years to act as an independent agent.

    When you fall into the trap of denigrating those who work in this environment, you undermine the chances that they will listen to you about using the very techniques and system approaches you are advocating. So, get off your high horses for a moment, and think instead about how you would solve this kind of problem. Stop thinking solely like engineers and try to apply some other disciplines (e.g., pyschology, negotiation).

    There are a number of us out there who are actually trying to implement the approaches you would advocate. Please give us a little credit for trying to adapt them to our environments rather than just saying we are dolts who obviously don’t understand.

  12. Paul, you bring more questions than answers, more criticism of engineers than helpful insight, and more “we’re different, you’re dolts” defensiveness than dialogue. I don’t think it’s moving the conversation forward.

    You say, “When you ask a question like this — “Even if a doctor has a unique set of skill should they be allowed to work around a system based on the patients safety?” — you are showing a high level of naivete or lack of understanding.”

    So what is the answer to that question you posed? Is it wrong to even ask the question? Are doctors that thin skinned? Or is it the administrators? What is the understanding we lack other than “you’re different?”

    There’s a difference between “understanding the underlying culture” and making excuses for it.

    We’ve tried discussing on this blog “why” doctors don’t always wash their hands, as one example of a cultural challenge. What is the answer? Why can’t it be changed?

    Can anyone else answer that?

  13. Paul – your unfounded attacks on engineers are as annoying as our perceived attacks on the medical world, I’m sure, maybe that’s an intentional point you’re trying to make to use, but I still don’t see the point.

    I don’t buy this whole “you’re thinking like engineers” crap. We’re thinking of the customers (the patients) when we ask why better systems aren’t in place for safety — what are you thinking of? Not offending doctors? Get real. When I’m in a hospital, I’m a jerk, I tell them all to clean their hands, and if they’re annoyed at me so what.

    Back to the Lean philosphy (for those of us who are managers and/or more well rounded than your view of an engineer), it’s very much based on psychology (thanks to the teachings of Dr. W. Edwards Deming and others). Lean, done right, takes care of customers AND employees. We focus on systems to prevent problems rather than having to blame people when things go wrong. Good engineers also think about all of these things, especially people who design systems. So maybe medical people NEED to start thinking more like engineers and quit screwing up so much. Engineers have done a much better job improving airplane safety than the medical profession and industry has done improving health care safety. So get off your own high horse. You’re new to that industry, it seems like you’ve “gone native” as they say.

  14. I guess I’ll just give up on this site (again). Everything I say is viewed as an attack or making excuses. Maybe it is my poor writing style, or maybe it just takes more words than can be put in a comment like this. If you want to read more about the approaches we are taking at BIDMC, you can read my blog. And please compare us to your local hospital and let me know — on my site — what makes their process a more effective one. We are deeply interested in doing this better — but there are strikingly few examples.

    But I will tell you, in all honesty, that the very kind of language you have used would make it difficult for you to be successful in the health care environment. I am an ally in pursuing the techniques and approaches you advocate, and when I try to suggest that you have not understood the underlying culture of hospitals and doctors, you dismiss me out of hand.

    Thanks very much for the back-and-forth, though.

    As to why doctors don’t wash their hands, ask them yourselves and see what the answers are. I have done that, dozens of times; but any recitation of what I have learned that I give on this site will certainly just be described as an “excuse” or as part of a characterization of me as having been “captured” by that profession. So I will leave it to others to try to explain.

  15. Paul and others,

    Please don’t dismiss the value of the discussion – unfortunately, some of the words used by both sides could have been better, and have alienated the parties of what could be a productive discussion. We know the Lean methods work in healthcare. And we know the nature of the business can be a frustration in making things happen. As one who work for a hospital and is a Lean advocate, I’ve seen firsthand the difficulties, and the successes. As in any industry, and as we saw in the early days in manufacturing, it takes awhile to figure out the best way to “reach the organization”, including, in this case, the physicians. So if we can refrain from the name-calling that’s been a part of this interchange, we can bring a productive dialogue forward. Lean works anywhere – it’s just a matter of finding the right formula. Let’s work together to bring positive change to our organizations.

  16. Paul, thanks for trying to enlighten us, seriously. I will continue to read your blog and will continue to admire your successes and your openness, in general.

    You have struck a pretty negative chord with this blog’s audience, which if you read other posts and comments, this is not normally a group that turns on people. I hope you’d take that into consideration. It probably *is* that your words come across as attacking, defensive, and excuse making – if you want to attribute that to bad writing, so be it. If this group jumped to conclusions and accusations about your industry and field, I think you did the same, unfortunately, which didn’t help the level of discourse. Offsetting penalties, I suppose. Loss of down.

    We criticize many companies and leaders in many industries as “dolts” (as you described our words) on this blog and maybe we shouldn’t. I try very hard to work at the “respect for people” aspect of Lean, in terms of not criticizing others or attacking them without trying to put ourselves in others shoes and asking “why?” first, whether we’re attacking dolts who layoff employees with Lean, dolts who take exorbitant pay while their company crumbles, dolts who provide horrible customer service, etc. You’re not alone in being criticized, you are unique in stepping up to try to respond, which I admire. I just wish we had turned this into something more constructive.

    My initial post on your blog were some questions, no attacks or snottiness on my part. I asked why the problems turned up by JCAHO weren’t addressed earlier and more proactively — a question I still think is a fair one. I thought my questions were posed in an inquisitive and respectful way. You responded with “hospitals are different” so we’ll have to leave it that…. it’s too bad we didn’t get much beyond that level of discussion. Maybe we’ll get there eventually.

  17. Boys, settle down, and get along now.

    Mr Levy said, this morning:

    “The issue is not that the doctors don’t care about patient safety, and it is not about their being greedy — it is that medicine has never been built around the idea of systemic improvement. Instead, it is a cottage industry, in which each provider has been trained for years to act as an independent agent.”

    So Mr. Levy is implying a root cause is the medical education system? I wonder what is being done, then, to train everyone in the hospital system to be team players then?

  18. Or perhaps you’ve discovered far more…

    It may (is?) not limited to the medical education system. Having spent the last six years working with Lean systems, after receiving a degree in Management, I wish I could have received education on Lean techniques before I entered the job market. The best (and only) class I had was Industrial Management, where a new professor (both to the school and to any post-secondary educational system) shifted the class into TQM (you gotta love those classes in the early 90’s!)

    This spring, a son of our V.P. graduated with his MBA from a prominent school in the US (which I will not name). During his undergrad and his masters courses, he had NO oppportunity to learn about Lean. He did, however, learn some details from our plant, as he Interned here during the summers. How is it that our educational system cannot see the benefit of 1)Waste reduction within their own system or 2)The value of teaching waste reduction to our future?

    I am currently working on a project with our local university (it’s a small school, but it’s a start!) I intend to be a guest lecturer throughout the term, providing some insights into Lean Systems. I hope to include some hands-on practicals in the lectures as well…perhaps a “go and see” then report back. Our local university is open to the idea, but (like traditional management) seems to be very slow to move forward.

    Still, we have to start somewhere, right? If education is key, we need to drive it back to our suppliers. However, we can’t expect them to take on the entire load. We must be willing to assist them and take on some of the burden.


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