David Sundahl on Adaptive Design, Scientific Thinking & Lean in Healthcare

Episode #86 is a conversation with David Lawrence Sundahl, PhD, Managing Director of Rule 4 Consulting. They are a firm that works with healthcare providers to drive improvements using Lean and what they call “Adaptive Design” methodologies. Sundahl was a contemporary of Steven Spear at the Harvard Business School and also worked with Dr. John Kenagy, author of the book Designed to Adapt: Leading Healthcare in Challenging Times.

Sundahl explains Adaptive Design–teaching teams to run lots of small scientific experiments at the point of care, starting with structured observation (minute-by-minute) to replace assumptions with facts. He shares a vivid example: turning an 11-page DNR policy into a short, testable checklist (wristband, chart, grease board, telemonitor), enabling nurses and a unit clerk to solve a long-standing safety gap in minutes and then spread learning responsibly.

The discussion digs into Rule 4 (“every improvement at the closest level using the scientific method under a teacher”), why psychological safety must be made tangible through rituals that welcome problem-finding and even celebrate failed tests, and how leaders can “meet people where they are” without accepting the status quo. Listeners will pick up practical approaches for building daily scientific thinking in hospitals–tool-agnostic, patient-focused, and designed to work amid healthcare's complexity.

For earlier episodes, visit the main Podcast page, which includes information on how to subscribe via RSS or via Apple Podcasts.

Transcript

ADS: Celebrating our 20th year of Lean Podcasting. Hi, Mark Graban here. Are you ready to go beyond the tools and learn what Lean healthcare really looks like? This October, I'm leading a small group of healthcare leaders to Japan. We'll visit hospitals and some of the very best factories.

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ADS: It's a simple way to support the podcast and to help keep us bringing you great conversations about Lean leadership and continuous improvement. And just tap subscribe in the Apple Podcast app to get started. Welcome to the Lean Blog Podcast. Visit our website at www.leanblog.org. Now here's your host, Mark Graban.

Mark Graban: Hi, this is Mark Graban. You are listening to episode 86 of the podcast for March 23, 2010. My guest today is David Lawrence Sundahl. He is managing director of Rule 4 Consulting. They're a firm that works with healthcare providers and organizations to drive improvements using Lean and what they call adaptive design methodologies.

Mark Graban: He was a contemporary of Steven Spear at the Harvard Business School and also worked with Dr. John Kenagy, author of the book Designed to Adapt: Leading Healthcare in Challenging Times. As always, I want to thank you for taking time to listen and I'd invite you also to check out previous episodes at www.leanpodcast.org, check out my blog at www.leanblog.org, and you can find me on Twitter at twitter.com/markgraban. Well, David Sundahl, I want to thank you for taking time out and joining us today on the Lean Blog Podcast.

Dave Sundahl: My pleasure.

Mark Graban: So as we normally do, I guess we just ask you to start by introducing yourself for the listeners. And I know you've got a particularly unique background, I think, for people that are doing work in this arena. So if you can talk about how your career has progressed and how you got to be doing this type of work, I think that would be great to hear about too.

Dave Sundahl: Good. I have sort of a standard joke that, you know, I did my PhD in early Chinese history and archaeology at Harvard. The natural next step, of course, is to become a visiting scholar at the Harvard Business School and then naturally that leads to health care. So that's a sort of joking way to explain what I've done. There are some common threads and one of the most important features or one of the most important threads that runs through all of this is actually how do you do good science?

Dave Sundahl: Whether that's as a historian or archaeologist, whether you're an academic at a business school or whether you work in a hospital or a manufacturing plant or you're a manager in one of these places, how do you do rigorous research? Not in the high end, big, big data set ways, but how do you do lots and lots of small scientific experiments? This was when I was at HBS. This was the stuff that Steven Spear, who probably many people know of, he was coming back and reporting on what he was learning. And really through all this, what became clear in his studies of Toyota is that everybody was doing small scientific experiments.

Dave Sundahl: Everywhere, from the maintenance guys to the plant manager, to the regional vice presidents and presidents, people were designing work as a way to test a hypothesis and then to improve. So that got me really excited. And at the time I was there, a mid-career surgeon, a vascular surgeon named John Kenagy was also visiting at the business school. And John persuaded Toyota to do a couple of pilot programs at hospitals. Because as we talked about this, I mean, his recognition or realization was that the things that Steve Spear was describing when he reported on what he was learning really weren't about making cars.

Dave Sundahl: He was discovering how to manage or how an organization has very successfully managed complex dynamic work. And nothing, I have to say, given my experience now, nothing compares to healthcare in terms of complexity and in terms of change. So we did this for a while, John Kenagy and I did, and we were Kenagy Associates for some time. Maybe that's the way to say it. And then John has gone to focus.

Dave Sundahl: He wrote a book on what we've come to call adaptive design. And we've really focused on the teaching, training, consulting stuff while he focuses on writing and evangelizing because he's such a good public speaker and he's a doc and he gets excited. As we had our firm created out of one firm, these two sister firms, we called ourselves Rule 4 Consulting. We take this, we've stolen Rule 4 shamelessly from Steven Spear's rules in use from the “Decoding the DNA of the Toyota Production System” article from the Harvard Business Review. And the fourth rule is that every improvement is done at the lowest possible level in the organization using the scientific method under the guidance of a teacher.

Dave Sundahl: So there are two features that–there are three features of it, but two that are really exciting to us for a lot of reasons that you might imagine. The first for me is every improvement is done using the scientific method. And we see ourselves as being the first wave of teachers for an organization so that they can begin to really absorb and adopt the tools and practices and the mindset that will help them to be successful.

Mark Graban: Okay, and so Rule 4 Consulting is doing that work exclusively within healthcare, correct?

Dave Sundahl: Yes, we only do healthcare.

Mark Graban: So tell us, you talk about the scientific method and can you describe how you might help get an organization and their staff members started in terms of what you're teaching them, what early actions that you have people take to learn how to do these experiments and to make improvements? Maybe talk about how adaptive design may differ either in philosophy or in the approach of how people go about that, how it differs from typical Lean, if you will.

Dave Sundahl: Surely. We use what I'd say is we use a lot of the same tools that Lean does. We are, on the other hand, we're a bit tool agnostic, so we're happy to have tools from any methodology. And I'll just have to confess, I'm not a great process engineer.

Dave Sundahl: In fact, there are many, many, many, many people who are much better than I am. And that's because our focus with our clients and other partners is we're really trying to get them to start to operationalize these ideas every day. So we talk about ideal patient care. We have a definition for it. Our clients will customize this somewhat, but it essentially amounts to, you know, each patient gets exactly what they need, when and where they need it, in a perfectly safe environment that's free from waste.

Dave Sundahl: And so that sort of defining ideal is the kind of starting point. And then we sort of teach this in two ways. One is just really practical with nurses and techs on the floor. We teach them to observe and then we serve early on as basically, say, problem solvers. We teach them to identify problems and then to participate in problem solving and to set up new, I shouldn't say new processes because in many cases they don't have any process, to establish a process that they can test against the real world.

Dave Sundahl: This is one of the wonderful things that the folks who really gave life to Six Sigma realized is that if you have a ton of underlying variability, it's really hard to know whether what you do is causing the effects you see or if it's just accidental. So on the unit, we try to help people make really small changes, but be really rigorous about them so that they can learn from them whether they come out as expected or not.

Mark Graban: So they're in designing that change, they're stating a hypothesis and testing to see if they get the results that they would have expected.

Dave Sundahl: That's right. And we think about the scientific method as you have a hypothesis, you test it against the real world. And if it comes out right, then you have corroborated but not confirmed your hypothesis. Because eventually you'll come to a point where you'll recognize something, some anomaly will happen, or you'll see another opportunity. That's great because that enables you to build a better theory, a better hypothesis about the world.

Dave Sundahl: We learn something, and so we just try to get them identifying where things are preventing them from getting patients what they need, building a system, and having that system every time, well, having that system be tested every time it's used. So I can give you an example of this to kind of as a kind of comparison for how things go in a hospital. Typically sitting on a unit, the nurses and the unit clerks are identifying problems. This is now several years ago, one of the early experiences we had, and a nurse said, “Okay, you wanted problems, I have a problem. This patient had a DNR order, and I just now discovered it as I'm going to discharge him.”

Dave Sundahl: So he was being discharged. So there was not much we could do for him then. But we wanted to figure out how to create a better system. We pulled the hospital system's policy on do-not-resuscitate orders. It was 11 pages long.

Dave Sundahl: And really there were only four things that mattered, four little things that mattered in all those 11 pages. And they were simply, you needed to have a red wristband on the patient, you needed to have red tape on their chart, red tape on the grease board. And then if they had a telemonitor, you needed to have red tape on that.

Mark Graban: And not to sidetrack your story, but that reminds me a lot of the points Dr. Gawande makes in his book, The Checklist Manifesto, that good checklists are short and to the point and really have the key things that are important to make sure you don't forget.

Dave Sundahl: Right? That's exactly right. And so, you know, it's interesting to hear the nurses talk about it because one of them had been on the DNR task force for 10 years. One of them had resuscitated a patient in the 80s and almost quit. So this was near and dear to their heart.

Dave Sundahl: So what did we do? We actually sat down for, it was 20 minutes. We did, you know, I did some legwork because I was there just starting that whole process for them, got a few things together and they designed a great process that worked perfectly for the… I was with them for another six weeks, it worked perfectly eight more times. And you know, it doesn't matter.

Dave Sundahl: The process itself is not so important. What's important is in just about 30 minutes they were able to solve a problem that the hospital system had been struggling with since its inception. Wow. And it's interesting, as we went to share this around, other places said, “Oh no, we don't have any problem with this because we do it this way.” So we're happy about that.

Dave Sundahl: We're not trying to force anybody to fix something that isn't broken. But other places were delighted to hear that somebody had some way to do this and they had to modify it to make sure it fit with their circumstances. But these nurses and that unit clerk made a huge difference for a lot of patients.

Mark Graban: Yeah, I mean, that's great to hear. I mean, I know from my experience that teaching staff members, front-line staff, some of these tools, leads to some amazing insights. I'm curious to hear more. You talk about teaching the staff to observe work, how you go about that or what are some… I mean, you've already talked a little bit about some of the surprising things that they see, but I'm curious a little bit more of that process or what kind of structure goes around that observation rather than just saying, well, you know, “Just, you know, go out there for an hour.”

Mark Graban: There's more structure to it than that, right?

Dave Sundahl: Yeah. We usually start people out with the same observation, which is a minute-by-minute observation of the activities of individuals so that they just get… they really are forced to see things happen rather than to report what they think would happen. That's why we start with activities, because lots of people can tell you what, “Well, this is the process for getting somebody into surgery.” And when they tell you the process, they're missing a lot of steps or they're adding things that they think should happen but don't really happen.

Dave Sundahl: And so we take people just to do an hour-long observation and we do a summary of that observation and we show it to the person who we've observed to let them know, say thanks and say, “Did we really get it right?” And this is principally to just get them to be comfortable observing rather than assuming. So we do this first with the folks who are going to be the support for the frontline folks, and then as they begin to create slack in the system because they're eliminating all sorts of hassle stuff. Then, you know, regular, front-line nurses or nurse educators, somebody will become… These folks will start to learn to become kind of team leaders for the, for the next group or for the group that's already there.

Mark Graban: So, yeah, it's funny you mentioned, you know, this gap between, you know, there's a difference between observing and assuming because I've seen there's often a big gap and usually to me, a big red flag is the word “should” when people say, “Well, we should do such and such.” Well, let's go and confirm and observe and see. Not to be too Yoda-like, but say, well, there is no “should.” You either do or you don't do.

Dave Sundahl: That's right. Yeah, this is one. It's really… this is a big thing in healthcare because everybody is so worried about doing the right thing that it often is difficult for them to give up the kind of normative stance. Right.

Dave Sundahl: So this is the way it should be. It should be. It should be. You know, what I always tell them is I think that the sun should rise in the south instead of the north, but it doesn't. So I'm just going to work around its schedule and I'll be happier and more successful if I accept what there is.

Dave Sundahl: Now, that obviously isn't… If you go too far that way, we're just giving in to things that can be improved. But at least we have learned the hard way, I think over the years that there's just no way you can be successful if you don't meet people where they are. If you don't meet them where they are, if you don't accept the way things are, then you just don't get anywhere.

Mark Graban: Sure. I mean, it sounds like what you're saying, understanding an accurate current state doesn't mean you accept it always has to be that way.

Dave Sundahl: Yeah. So that's a much… You've said it much better than I have. You're right. Yes.

Dave Sundahl: But without that correct understanding, you're just sure to get yourself in a lot of trouble.

Mark Graban: Yeah. One other thing I want to touch on before we wrap up and maybe along the lines of people getting into trouble. I mean, I'm curious, situations where you're teaching staff to see waste and see problems and to identify problems. A lot of organizations and cultures don't exactly reward that simple act of identifying a problem. And so can you talk about some of the things that you maybe work with, with managers or senior leadership on to create an environment where that approach can actually not lead to bad reactions.

Dave Sundahl: Yeah, this is a case where the principle of sort of batch size of one, one-piece flow or sort of customization one by one is really important. We have learned, we've tried a number of interventions to create, to increase psychological safety in a broad sense in organizations, but it turns out that people, again, are built somewhat differently. And over the decade we've been doing this, what we've really learned is that some people will… they can make this… they can just make this turn really easily and some people can't.

Dave Sundahl: And what we have to do is go diagnose the barriers they're having because actually people do… they get it cognitively, it's that emotionally, they have a hard time with the idea of welcoming problems. And so in a way, we just structure activities that allow them to demonstrate to the people that they work with especially that they value. Now, that might be setting up some kind of ritual where if you've identified five problems, you get some treat. Or it might be the first time an attempted improvement fails.

Dave Sundahl: We try to have a leader come to the unit to celebrate the failure of our hard work. It sounds crazy, but sometimes that's all it takes for them. They just need a ritual to be able, you know, they need standard work for celebrating problems being raised and failures, even of our best attempts at making a better process being accepted and welcomed as an opportunity to improve.

Mark Graban: Well, I appreciate you sharing some of those ideas and some of the approach with me and with the listeners today. I want to thank you again, David Sundahl from Rule 4 Consulting for taking some time out. Can you mention a web address or other ways that people can learn more about your firm and the work you're doing?

Dave Sundahl: So we'd love to have you come to our website. It is just www.rule4consulting.com, so rule, the numeral 4, consulting. And you can kind of read some case studies. We have a blog that I don't, that I don't do a great job with, but I keep, you know, putting things in here and putting things in there. And I've now got another author who's helping me out and he's more reliable.

Dave Sundahl: Because we get lots of good stories, so. And we'd love feedback on what we misunderstand or get wrong, so.

Mark Graban: Well, good. I hope listeners and people will go check that out and learn more. I want to thank you again, David, for taking the time to join us today. It's been great having you.

Dave Sundahl: Thanks to you, Mark. It's a real pleasure.

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