Is Lean Management a “Slow Idea”?
I just read Dr. Atul Gawande's latest piece in the New Yorker: “Slow Ideas: Some innovations spread fast. How do you speed the ones that don't?”
Gawande compares two new medical technologies from the mid 19th century: anesthesia and antisepsis. Why did one new practice spread more quickly than the other?
When surgical anesthesia was invented and proven, it only took a few months to spread around the world (an in days before modern communication technology):
The idea spread like a contagion, traveling through letters, meetings, and periodicals. By mid-December, surgeons were administering ether to patients in Paris and London. By February, anesthesia had been used in almost all the capitals of Europe, and by June in most regions of the world. Read more
Whereas new methods for preventing sepsis and surgical infections, a much quieter problem than a patient screaming on a table, spread much more slowly, even though there were “strikingly lower rates of sepsis and death.”
Gawande explores different theories about why anesthesia would spread faster:
- Economic incentives were equally well aligned for both new methods (good for doctors financially)
- Both approaches violated prior beliefs and were simply hard to believe
- Both methods required technical complexity (neither was easy)
There are some interesting mental models exposed in the piece, including the idea that discharging pus from a surgical wound “was thought to be a necessary part of healing” and that surgeons wore “black frock coats stiffened with the blood and viscera of previous operations” as “the badge of a busy practice.”
Gawande posits this as the key difference between the acceptance of anesthesia versus antisepsis:
So what were the key differences? First, one combatted a visible and immediate problem (pain); the other combatted an invisible problem (germs) whose effects wouldn't be manifest until well after the operation. Second, although both made life better for patients, only one made life better for doctors. Anesthesia changed surgery from a brutal, time-pressured assault on a shrieking patient to a quiet, considered procedure. Listerism, by contrast, required the operator to work in a shower of carbolic acid. Even low dilutions burned the surgeons' hands. You can imagine why Lister's crusade might have been a tough sell.
This has been the pattern of many important but stalled ideas. They attack problems that are big but, to most people, invisible; and making them work can be tedious, if not outright painful. Read more
Does Lean Healthcare solve problems that are “big but, to most people, invisible?” Is the work required to become a Lean thinker and a Lean organization “tedious, if not outright painful”?
Although hospitals (and their employees and patients) are suffering from poor quality and patient safety problems, low morale, long waiting times, and financial difficulties, hospitals have a choice between doing more of the usual (such as merging, scaling back services, and laying off employees) or managing differently and reducing waste (through Lean).
Hospitals rarely get criticized for NOT trying a new approach to structuring and managing their organizations. They can point fingers and blame outside factors (like sequestration and the Affordable Care Act) and who criticizes them for being in a challenging industry?
Gawande writes about how healthcare is addicted to fancy new technological solutions. Lean management requires diligent analysis and disciplined daily practice. It might seem boring to some.
The article also explores the lack of adoption of good practices for childbirth and post-natal care. Even when proven “best practices” are simple and require no money or resources, they are often not adopted (yet hospitals spend money on new technology that might not be as effective).
Gawande explores three common methods for trying to get people to adopt a new process (think about this in terms of something detailed like hourly rounding or a higher level adoption of Lean methods):
- Saying “please do X” to people (“it works, but only up to a point”)
- The “law and order” approach of “you must do X” – this works, but people with rare skills will often just quit their jobs under threat of punished for something
- Offering incentives (the “kinder” approach to #2) – it's really hard and complicated to manage this
None of the three “achieve what we're really after: a system and a culture where X is what people do, day in and day out, even when no one is watching.” I agree that's what we're looking for.
We can say “please adopt Lean management.” I would be in favor of “mandating” it, since hospitals would probably do the bare minimum required to satisfy government regulators that they are “implementing Lean” and positive incentives could be gamed or fudged.
So how do we create change? Gawande suggests a few key approaches:
- You have to “understand existing norms and barriers to change,” understanding “what's getting in their way.” This requires a lot of one-on-one mentoring of people.
- “Evidence is not remotely enough,” as you need “seven touches” in talking with people seven times
- Having seven key, easy to remember messages or pitches about the idea
Gawande shares examples of changing norms around the world. He talks about people being given classroom training and then being visited on site “to observe as they try to apply the lessons.” That's coincidentally the same approach I take with my “Kaizen Kickoff” workshops – classroom time and one-on-one mentoring and coaching. Kaizen (the practice of continuous improvement) also seems like a classic “slow idea.” But, it's spreading.
As usual, Gawande's article is full of rich examples… there's a lot to chew on and to talk about. What other things stood out to you in the article? Read the full article.
You can also see Gawande's recent appearance on The Colbert Report: