Yesterday, I blogged about a CNO who was changing the culture at a hospital away from blaming individual nurses for system problems.
The HealthLeaders article I wrote about didn't talk about “Lean” per se. But, that single idea about moving away from blame is probably one of the most powerful notions from the Toyota Production System (which was influenced heavily by W. Edwards Deming's views on this).
Deming said the CEO and senior leaders are responsible for the system — and the system includes the culture and management system of an organization.
In January, I blogged about some concerns that had been brought up by the unions at Zuckerberg San Francisco General Hospital about overwork and how Lean should be part of the solution to that long-standing problem.
As I blogged about yesterday, new leadership behaviors (sometimes as the result of getting a new leader) can make a huge difference for an organization — this was true during my time at General Motors and I've seen it in healthcare.
In some cases, as John Toussaint has talked and written about a lot, he was able to change his own behaviors away from what he calls “white coat leadership.”
I don't know Dr. Ehrlich, so I'll presume that Toussaint is co-authoring with her because she is going through that personal leadership transformation (and that's something that takes time for anybody). It's not like flipping a light switch. You're not a “Lean leader” or “not Lean leader” in some strictly binary way.
The article begins:
“The behavior of senior executives, and especially the CEO, is known to be directly related to an organization's performance.”
That's all the more reason for executives to stop blaming employees for bad results — transformation starts by looking in the mirror. Lean isn't about training, certifying, or fixing the front line staff. Culture change starts at the top.
I agree with their assessment of history and what's too often, still, the current state in healthcare organizations:
“Health care has been slow to adopt modern management principles. Most health care organizations are still managed in a traditional autocratic style that does not allow for much worker input. The manager or leader makes most decisions and tells everyone what to do. “
If that autocratic model worked, then healthcare wouldn't have the problems it has today, including major patient safety and quality issues.
“Many hospitals around the world are building a different management system to combat this unacceptable medical error rate. Leaders are taking lessons from world-class manufacturing and software companies to build systems that transfer decision-making to those who do the actual work.“
I don't know if “transfer” is really the right word to use about decision making.
Leaders can better ENGAGE and INVOLVE those who do the actual work in decision making and problem solving.
But, the reality is that the front-line staff can't fix the bigger systemic problems that interfere with them providing ideal care.
Nurses and other front-line staff can make small “Kaizen” improvements in the details of how their work is done. They can participate in broader “value stream” improvements. But, nurses are powerless to fix things like chronic understaffing, balky computer systems, or bad business models.
As I've heard John Shook (formerly of Toyota and now with the Lean Enterprise Institute) describe it, Lean leadership is neither completely top-down, nor is it completely bottom-up. It's a blended model of delegation and empowerment, along with servant leadership. There are some problems only senior leadership can fix.
As Darril Wilburn, formerly of Toyota says:
“Leaders are responsible for providing a system in which people can be successful.”
Toussaint and Ehrlich write:
“In manufacturing, frontline workers have clear expectations that any problem identified in quality or workflow is their responsibility. The workers suggest ideas, test them, and make changes in real time.”
Again, I don't think that's really true. The word “any” should read “many.” It's critically important to involve front-line staff, but they can't do it all.
Research from Robinson and Schroeder (listen to my podcast about this) shows that about 80% of improvement results in an organization come from “small Kaizen” improvements — in other words, from front-line staff and managers tweaking and refining the process they work in.
So, front-line staff can do a lot — if the organization and its leaders create an environment where it's safe to speak up about problems and they're given time to fix them.
Toussaint and Ehrlich's description of the current state seems accurate in many organizations I've seen, unfortunately:
“In health care, on the other hand, a nurse with an idea to improve the patient experience typically keeps it to herself, knowing it would need to go through layers of management. It's just not worth her time.”
One of the hospitals featured in the HealthLeaders piece that I blogged about yesterday identified a systemic reason why the hospital had such trouble filling open nursing positions. They had a policy that said they'd only hire nurses with experience. Front-line staff couldn't change that policy, only the CNO could.
I understand why people stop speaking up when they're neither empowered nor supported by leaders. Professor Ethan Burris writes about the “futility” factor as the biggest reason why employees don't use their voice in the workplace.
Toussaint and Ehrlich again write:
“But for traditional health care managers, relinquishing responsibility for problem-solving to the people closest to the work is hard to swallow. It requires a different way of behaving.”
Again, I don't think it's a matter of “relinquishing” responsibility. Leaders can delegate problem solving work in many cases, but they don't give up “responsibility” for the results or for the system. Again, leaders can involve and engage more than they can relinquish or abdicate.
Strategy is one example of something that can't be delegated to staff.
“ZSFGH adopted six True North goal areas — equity, safety, quality, care experience, workforce care and development, and financial stewardship — and decided how to measure each performance category. These measures are ZSFGH's must do, can't fail metrics for organizational performance.”
That's great. That's an example of behaving and leading differently — trying to gain alignment around those goals and supporting people in their improvement work.
I've heard Toussaint say this a lot, including in this video:
“If organizations are to change, then leaders have to change.”
ZSFGH wants to encourage these behaviors:
- “willingness to change
- leading with humility
- curiosity of how things work
Behaviors like that need to be modeled and demonstrated by the CEO, Dr. Ehrlich, and other leaders who work with her.
Another key behavior described there is going to the “gemba” or the workplace to “observe, learn, and coach” through “open-ended questions” and “listening carefully.”
I'd presume that Dr. Ehrlich is leading by example in all of those behaviors.
I recently interviewed a healthcare CEO, Vance Jackson, who talked about the power of going to observe the work. The willingness to do this seems to be a rare trait in this field.
The article describes some the Lean management practices they've adopted and some of the improvements that they say are a result of those new behaviors. Some of those emergency department improvements are also detailed in this article.
Please do check out the Toussaint and Ehrlich article. What do you think about this?