Fire Fighting vs. Root Cause Problem Solving
Below is some of the text from edition #3 of the newsletter from my upcoming book Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction.
Hospitals are notorious for employing “workarounds” to respond to problems. For example, when supplies or medications are missing, the typical response is to run around, looking for what is needed. Once the missing item is found, the nurse might go back to their regular duties — problem solved, right?
The workaround does nothing to prevent the problem from occurring again — this ensures more wasted time and more potential problems in the future. It is not fair to blame individuals for this behavior, as workarounds and fire fighting are often encouraged by our organizational culture and reward systems.
In a Lean setting, we still “put the fire out,” if you will. If a medication is missing, the first response is to make sure the patient has what they need — get the med. But we then have to STOP and identify how to fix the process. Instead of blaming people or asking “who messed up?,” we have to look at the process.
Two simple questions to ask:
- How and why did this problem occur?
- How can we prevent it from happening again?
For the first question, you might use the “5 Whys” method of continuing to ask why until you reach something that really is a “root cause” rather than being a symptom/result of a more fundamental problem.
With the second question, we focus on prevention. Use “error proofing” methods or ensure that a standardized process and method is in place.
This approach is all about the mind set. If you are a manager and employees come to you with a problem or complaint (or to report fire fighting), be sure to ask them about stopping to identify the root cause. Work together with them on preventative measures. Be sure to communicate changes with the rest of the team.
Many people complain, “That makes sense, but I don't have time for that.” Have you gathered data on how much time is spent using workarounds and fighting with the current process? If you invest a bit of time on process improvement (even if it requires a few hours of overtime), you will likely find recurring time savings from improving the process instead of fighting the same fires over and over again.
One hospital pharmacy spent 11 hours a day processing medication that was returned from patient floors. Not all returns are the result of a process error, but many returns are the result of medications not being transferred to another unit along with the patient, for example. By dedicating some time to improving the process (delivering medications more frequently and working with nurses to prevent process errors), this time was significantly reduced. Those hours saved, time not spent processing returns, are saved each and every day.
As “fires” pop up during the day, there might not be time right then and there to stop and use the Lean problem solving approach. It can be useful to have a formal method of documenting problems that need solving as time allows. Sticky notes or note cards on a board can be a simple way of tracking these opportunities (don't hide the notes in a “suggestion box”). When slow times occur during the day, encourage team members to take a card off the board, spending some time on process improvement. Small improvements can often be made in a 20 or 30 minute window, as time allows. Almost all of us have some slack time in our day — it's just often not identified or utilized properly.
Hospitals can break the cycle of fire fighting — it requires dedication, some time investment, and continuous reinforcement from leadership until new habits are formed in the organization. When time is available in the day, are we chatting about “American Idol” or working on small process improvements (or “kaizen”)?
Here is an outstanding article from Steve Spear and Mark Schmidhofer titled, “Ambiguity and Workarounds as Contributors to Medical Error.”
Do you have examples of how you have struggled with breaking the fire fighting cycle? Have you been able to move toward root cause problem solving and prevention? Share your experiences on the message board or click comments to share your experiences here…
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“When time is available in the day, are we chatting about “American Idol” or working on small process improvements (or “kaizen”)”
BWA HA HA HA HA HA
Great post Mark! I found this hilarious since I have heard the American Idol conversation at all places I have worked!
“If you invest a bit of time on process improvement (even if it requires a few hours of overtime), you will likely find recurring time savings from improving the process instead of fighting the same fires over and over again.”
This might be seen as more fire fighting. Instead of working overtime, employ enough people so everyone has some otherwise-idle time to think about root causes and process improvements.
You raise an interesting question, Klaxophone. I think you have to be careful about hiring more people unless you KNOW you’re going to have growth so you can give them productive work to do, long-term.
If you hire and then drive waste out of the process, you run the risk of having more people than you need. We always want to be careful, with our lean improvements, that we don’t allow productivity improvement to drive layoffs. I think we also have a responsibility to NOT overhire.
I’m not sure if I agree that the OT would be a workaround. Chronic OT is probably a workaround for not having enough people (or for having too much waste). Short-term OT with a specific purpose might be much more cost effective (and more in lines with “respect for people”) than hiring new people and maybe feeling pressured to have to get rid of them after improvements are made.
I do agree with your point that everybody needs SOME “idle” time in the day to work on continuous improvement. You can’t run a machine at 100% utilization and you can’t run a person at 100% utilization either.
We now use this process in our morning meeting to help focus the group. Too often, I had noticed we kept jumping into solving the problem before we had identified the problem and determined the root cause. It helps us FOCUS daily when problems do occur.
Problem Solving – Rational Process
1. Which specific problem are we working on now?
Define the problem!
2. Do we know the cause of the problem?
3. Has the cause been fixed?
4. Have we reapplied the fix to other similar items?
5. Have we prevented it reoccurring?
KNOW WHERE YOU ARE IN THE PROCESS
When the answer is I don’t know, or no, STOP! This is the step which must be worked on. It is premature, and pure waste of time to discuss anything in the later steps.