Some colleagues and I had a chance today to spend some time with Steven Spear, from MIT and the Institute for Healthcare Improvement, who is an expert on the kind of process improvement program we are trying to carry out at BIDMC. That he had terrific and useful insights was no surprise to those of us who have read some of his work.
Steve also made mention of research carried out by Anita Tucker, from Harvard Business School, in which she spent many hours observing nurses in hospitals. (I did not find this particular study, but here is one that summarizes it.) Her conclusions were consistent with my own observations and the points I made in my staff email back in November -- and many comments I received from our staff after that email. Professor Tucker found that nurses who encounter problems or impediments on the hospital floors generally will invent a quick work-around to solve those problems. This makes sense. First of all, they are really busy and just need to get the problem solved. Secondly, most organizations do not provide a way to call out problems and have them solved in a timely or effective fashion. Unfortunately, this pragmatic approach to problem-solving leaves systemic problems untreated and, indeed, aggravated by an additional layer of work-arounds.
As Steve has written in his studies of Toyota and reviews of other high performance organizations, the common characteristic of these organizations is not in their ability to design perfect and complex production or service delivery systems. Rather, it is their ability to discover great systems. They do this by managing their work flow to encourage people at all levels to call out problems; to "swarm" together to solve those problems; to share this process of discovery with others in the organization so that the solutions are diffused widely; and to cultivate the skills of people throughout the organization to be involved in this kind of constant improvement.
It was heartening to hear this reinforcement for the kind of program we are beginning at our hospital, which was named BIDMC Spirit in our own election campaign. I feel like we are on the right track. Now comes the simple (hah!) part -- doing it. Our first training session was held today. Stay tuned for further developments.
Any chance you would let a very interested employee observe these training sessions for educational purposes?
ReplyDeleteOne system wide problem with a "simple" solution is for everyone to return a chart to the shelf after using it.We all spend too much time searching for unreturned charts.It shows respect for whomever we think is going to put the charts away after we leave (sort of like my 17-year old son...
ReplyDeleteKindly refer: Quote - As Steve has written in his studies of Toyota...."high performance organizations,...Rather, it is their ability to discover great systems. They do this by managing their work flow to encourage people at all levels to call out problems; to "swarm" together to solve those problems; to share this process of discovery with others in the organization so that the solutions are diffused widely; and to cultivate the skills of people throughout the organization to be involved in this kind of constant improvement." - unquote
ReplyDeleteHe is perhaps refering to the Japanese working in the complex japanese social system in Japan were 'Face'is most important and 'loyalty' takes on a completly different meaning. The same example may or might not completely fit in other cultures.
I am in japan for the last few days and am observing the great social pressures on people who are too polite to ever admit this.
Good to hear. Accountability goes a long way toward establishing efficient work systems while simultaneously minimizing frustration . Our program looks like it will address a problem inherent to the "team" approach, that being the "someone else on the team will deal with it" mentality.
ReplyDeleteWhat you wrote reminds me of an article I read recently in AJN about military nurses & the notion of “field expediency”. The article told some great stories from nurses during the Vietnam War; work-arounds & commandeering supplies & under-the-radar trades and deals they made.
ReplyDeleteWhen we feel we’re on the battlefield, our heroic nature comes out and we jump to solve problems quickly. Also, truthfully, we nurses do get a big kick out of our problem-solving prowess.
Perhaps the notion of “field expediency” may be helpful in helping BIDMC channel or harness the punch and creativity we nurses love to use; helping craft a culture that is clear about when using field expediency is worthwhile and appreciated, and when a field expediency mentality is not cool.
Creating a path of low resistance for quick problem-solving through proper channels will certainly help us keep up our pace without resorting to underground workarounds.
But best not to forget that we sometimes do just get a kick out of our own audacity.
Link to the abstract:
http://www.ajnonline.com/pt/re/ajn/abstract.00000446-200705000-00022.htm;jsessionid=HpKZtLCvWFqM6sXFdF2cQ2FTcnC92rNvNgLTy2BGG2TT8hntpVVj!1138671057!181195629!8091!-1
For an employee to be motivated to initiate a systems improvement rather than just solve their immediate operational problem two things seem to be needed. 1) A link to some hard measurable data similar to the Premier/CMS data being developed, and 2) the creation of a culture expecting individual imitative for the common good that is not stifled by the historical bureaucracy in most health care settings. Aurora Health care in Wisconsin has had some remarkable success in finding better ways in this regard.
ReplyDeleteUnderstanding that the Hospital main mission is the health of the patients, There seems to be a focus on this project on the Nurses problems/issues in providing the best health care services.
ReplyDeleteSomething that may come from all of this is my belief that the support systems are part of the cause of these work arounds.
What if the reason a supply is not on the floor goes all the way back to A/P, because someone left with invoices sitting on their desk and noone caught this. The vendor puts you on credit hold and until someone gets around to finding out why, the whole delivery system gets messed up.
Those who work behind the scenes also have alot of issues and workarounds. I am hoping that this project sheds some light on the importance of support systems, and maybe some respect will come to those who work there.
Diane Geggis
You are absolutely right. This program is not just about the nurses, but all support folks as well.
ReplyDeleteWent to engineering school and ended up as a computer programmer in the 70s doing manufacturing modeling. Then gave it up went into medicine became a physician. Then decided to work on the physician computer interface, and diagrammed out 22,000 patient visits in ERs, Medical floors, OR, ICU, Nursing home, Offices, And home visits. Then built a model, called "The Foresighted Practice Guideline Model" and it described medicine perfectly, and allowed for implementation and complete description and knowledge of the system. THis was in the late 80s and 90s. Using an object oriented dictionary data bank model. Did not realize that we were 30 years ahead of our time, until now, 2007-2008, but still "image and retoric are more important than substance and results."
ReplyDeleteThanks
TAN