Q&A #2 – Michael Balle, "The Lean Manager" – Nursing


I recently invited questions for Michael Balle, the author of the Shingo Prize winning book The Gold Mine: A Novel of Lean Turnaround. He has a new book (published by LEI, my employer), recently published, called “The Lean Manager.”

Here is the second Q&A. If you have a question for Michael, click here for more info on how to submit them. If you have a question in response to this post, please the comments feature. For previous Q&A, click the “Balle” link at the bottom of the post.

Q: You wrote an article that was floating around on the internet a few years ago about titled, “Lean as a Learning System in France“, where you described a two year conversion on a nursing unit to standardizing key nursing processes that started with addressing workplace organization. Is it your experience that it takes substantial time to do such a thing or is there a way to accelerate standardizing key processes?

Answer from Michael Balle:

MichaelBallePhotoThat's a question that I ask myself every time I start working with a new outfit. I'd love to find the magic wand one day, but barring that, I believe speed of change comes down to two factors:

  1. How good the teacher is
  2. how quick on the uptake the people are

And none of these are very good for speeding things up. Let's first get the teacher part out of the way – in my case, improvement there is terribly slow. Moving things along for the people you work with is not a factor of style or persuasiveness, but more the ability to hit the right leverage points fast – which can only come with experience. In any new setting there is a period where running kaizen events is mostly about figuring out what the real problems are in the business/company situation.

In this specific instance, when I started working in hospital wards ten years ago, I had no idea what I was doing, so by default I started on 5S which turned out to be a lucky guess. Thankfully I was working with some very good nursing directors and we started tackling higher payoff problems soon enough – but we're still talking months rather than weeks. When your sensei is experienced in your situation, change is faster because he or she is clearer about what is a real problem and what is not and how to go about it. In healthcare, that's something of a problem as I haven't come across many people who are at ease both with patient problems and lean principles. I'd say that every new cycle is marginally quicker than the last one, but progress there remains slow (maybe I'm just a slow learner).

Assuming the sensei knows what he or she is doing (big assumption there), the second part of the equation is people's learning ability – and there, you get a very large variation. At the ward level, performance is mostly an organizational matter – attention and competence. There are few machines to set that “make parts.” it's all in people's hands and heads.

Ultimately, your performance is a direct result of what staff and ward management have understood of what they're doing – or not. The lean exercises are all about helping them along the learning curve. So what typically happens is that one person out of ten is a natural (why hasn't any one ever told me this before?) and improves things very quickly. They usually already ran a pretty good show, but now they have a technique that shifts what is possible and turns a lot of the “not possible” into “not impossible”. Then you've got a couple who are hard workers and willing to try hard, but don't “get it” easily – it's going to take time. And the rest will never buy into it, so you're going to have to pressure them (either direct or through peer pressure) in cleaning up their act.

Now the good hews of healthcare is that, in my experience, doctors and nurses are absolutely dedicated to do what's right for the patient, but have often painted themselves into a corner of “learned helplessness” – accepting that the system gets in the way of them doing what's best for the patient. They then start to go around the system randomly which creates even more confusion and so on. So when they “get” the fundamental mechanism of respecting standards on the one hand and doing kaizen exercises on the other things can move quite rapidly.

In the specific case of the hospital the paper is about, we were looking at a smallish hospital with five wards (one per floor). The nursing director I co-wrote the paper with already ran a tight ship and, at first, I wondered where to start, but of course I did my party trick of opening randomly a cupboard, putting my hand at the back of the shelf and fishing out an out of date product, so we knew where to start. In this case, one of the ward managers picked lean faster than I could teach (I saw them about once every couple of months), the others were slower and the outpatient clinic never wanted to anything to do with the program – even when it was shown to succeed quite visibly elsewhere. The physiotherapists kept oscillating between wild enthusiasm and “whatever” and we never made much progress there either.

Ultimately, continuous improvement is, well, continuous. In my experience, the good pace is one kaizen something (event, workshop, lunchtime discussion, whatever) per manager per month – that's not a program thing but a psychological time. Faster than that, they don't have time to do their work. Slower, they have time to close the file and move on, and then have to open it up. The key question is maintaining this “takt” of kaizen and focusing on the standardization issues that come out of the kaizen one issue at a time, so that people get used to the PDCA cycle.

In terms of performance results, I don't have a definite answer, because it completely depends on how good the sensei is, how quick the students are, and how good their relationship with themselves and the rest of the staff is. If push comes to shove, I'd say we're generally looking at six months to one year of figuring out what the real problems are (you get quick wins all along), a second year of stabilizing the situation and getting into basic standardisation (more low hanging fruit there) and then some real kaizens – care improvement at patient level – start not only to appear but to be maintained, because enough people are on board and are getting into the practice of standards and kaizen.

I don't know, what's your experience with it? I'd be curious to find out any data on that theme.

Michael is the co-author of The Lean Manager and The Gold Mine, and can be contacted at: http://michaelballe.org.

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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.


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