Exceptional Efforts in Imperfect Circumstances – Celebrated or Lamented?
Here's a thought starter for a Monday morning – I'm looking forward to hearing your perspectives. A few weeks ago, I heard a leader from a healthcare organization (one that will remain unnamed) say this:
“In healthcare, we get results from people's exceptional efforts in the face of imperfect circumstances.”
The exact sentence is paraphrased but these four words are exactly what was said: exceptional efforts… imperfect circumstances.
I've heard that said before… but what struck was the sense of pride behind the sentence in this case.
Healthcare is full of heroes. That word applies on a few levels. There's the inarguable heroism of somebody who can save a child's life when their heart has stopped beating or when they have cancer. That's nothing but goodness. We should all be thankful that medical professionals have the skill and drive to make that happen.
The other kind of heroism isn't always helpful – in the long term. This form of heroic activity is often chalked up as “fire fighting.” It's a mixed bag – in the moment, the “exceptional efforts” are very necessary in light of “imperfect circumstances.”
I'm reading the book by Peter Pronovost, MD, called Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out, and there are many examples of both the fire fighting and the imperfect systems.
Let's say a physician is about to insert a central line catheter into a patient. This is a risky proposition since there are, on average, 2 infections per “1000 line-days” and up to 25% of these infections are fatal. As Pronovost's work on checklists showed, a simple set of tasks can virtually eliminate these infections. They are “largely preventable,” Pronovost says.
Pronovost cites these stats in his book:
…infections from central line catheters is four infections per thousand catheter days (a catheter day is one day that one patient has a catheter). That means each year roughly eighty thousand patients become infected as a result of placing central lines, and thirty thousand to sixty thousand die, at a cost of up to $3 billion nationally.
But if there's a proverbial fire — let's say that one of the basic central line supplies is missing, like one of the drapes. A nurse might be a hero — go through an “exceptional effort” to race down to another unit to get that drape. That might delay the doctor, meaning other patients have their care delayed. The “imperfect circumstance” is that there's not a good system to make sure everything is stocked properly — materials are found where they're needed in the right quantity 100% of the time (that would be the Lean goal).
Pronovost confirms what we see from a Lean perspective, that these “imperfect circumstances” are common:
Furthermore, the way this work is organized, or in many cases not organized, often prevents patients from receiving the care they should; supplies are not stocked, labeling is ambiguous, communication is vague, absent, or confusing, and critical equipment is sometimes simply just not available, even at America's best hospitals.
The problem with being a hero is that there's another fire to put out. It's easy to rationalize putting out other fires — after all, you're helping in the short-term. People are under time pressures, so they move on — put the fire out (exceptional effort over) and they don't stop to address the systemic imperfect circumstance. “We don't have time to fix the system,” is a common lament. Many organizations seem to accept “lack of time” as an excuse instead of a problem that can be solved. The Lean approach would ask “why isn't there time?” and “what can we do to create time by eliminating waste?”
Lean thinking is powerful in that a Lean organization finds the resources and the time to put out the fire and THEN finds time to fix the system. It might be the natural work team that does this (an ideal state, people who do the work fix the work) or it might be a Lean project led by a specialist resource (or even a Six Sigma project).
Being a hero is fine if you're not constantly putting out the same fire every day. To really improve quality and ensure consistently good care, we need to fix the system. In the above example, when the system isn't fixed, the physician might be tempted to cut a corner the next time and insert the central line without the proper draping (yes, it's conceivable that would happen. A patient might get an infection because the full checklist wasn't followed.This is a systems failure, not solely the fault of a “bad doctor” who made a bad decision – life's not that simple (and this is a theme in Pronovost's book, that we have to move beyond blame to look at underlying systems that create these bad situations).
Pronovost writes about the rational decisions people make to, under time pressure, NOT be a hero (although they ideally would):
Time she spends looking for the antiseptic is time not spent with her patients.
Without fixing the system, the “exceptional effort” that helps Patient A might be a detriment to Patient B, Patient C, Patient D, Patient E, and maybe Patient F.
The very same drive and ability to constantly be a hero might be just the thing that holds back improvement of the overall system. So while the person I referenced at the start of the post spoke with pride about the “exceptional efforts,” a Lean thinker would typically say that exact same sentence with a bit of remorse that the “imperfect circumstances” are so easily tolerated. Exceptional efforts are good. Eliminating imperfect circumstances is better.