"No such thing as bad student, only bad teacher."

As we head into day two of our Lean workshop here at Jeroen Bosch Ziekenhuis (hospital) in the Netherlands, it is good to reflect on the nature of complex organizations and the messages given by an organization's leaders to the staff.  Why is it that people in hospitals engage in wasteful activities and behavior?

I posed the question in a slightly different form to our participants as a huiswerk (homework) assignment, asking them to write a short essay in response to this true-false question:  "Waste exists at JBZ because people are uncaring and lazy.  Provide evidence for your answer."  As expected, the unanimous answer was "false," and people offered the following commentaries. 

John replied with some evidence of the staff's good intentions:

Last Saturday we had an disaster exercise where a few hundred employees of the JBZ took part on their day off.  We saw a lot of enthusiasm and willingness to learn.

The employees on my unit are happy to share their knowledge with other units, in collaboration, teaching, exchanges.  They also did this for a television series about emergency care.

Anne-Marie agreed about these good intentions:

The willingness of the staff is great. They are willing to do something extra.

Monique observed, though, how people can be trained to become resigned to the way things are:

Employees are often not listened to when so they report on a problem. When people say something several times, where nothing is done, they get a resigned attitude and do things no longer. 

Hélène expanded on this thought:

 

If nothing is done by managers with signals of ineffectiveness from the staff, indifference arises and there will be more wasteful actions. 

Judith concurred, noting the inevitable presence of inertia in such situations:

A lot of things that we do we do because “we always do this like that”.

Or, noted Paul, the staff are forced to invent work-arounds:

The employees are very creative in circumventing problems that occur, causing many inefficiencies.

And then Monique offered the following underlying causes:

There are too many islands in within the hospital.  People can not or will not "watch each other's kitchen" so everyone re-invents the wheel and things are not aligned. 

If you are a long time in the same spot you will get, whether you intend to or not, a tubular vision. Someone from outside your processes can give you a whole new image and ensures that your own eyes widen.

Riny gave a similar diagnosis:

People who work in the JBZ are certainly not lazy and indifferent. It is working protocols and regulations that are not kept up to date that cause waste to occur. People in the JBZ work hard but must abide by certain old rules that are not based on the current situation. This results in noise and miscommunication, making much unnecessary work.

Jacqueline agreed, noting:

Preconditions do not always exist for employees to be efficient, and to experience the pleasure of  satisfaction. This frequently leads to demotivation and resignation.

Karin asserted that change is difficult because of the multitude of constituencies found in a hospital:

The people working there are involved and are willing to think about changes and improvements. Very often, secretaries in the clinic indicate that some things do not work. Often they already have an idea of ​​how it could be otherwise. To carry out these solutions, though, is complex. Often they must then be discussed with other stakeholders (other secretaries, nurses and medical specialists) because they would also have consequences for those people. Sometimes there is no agreement about the proposed solution.

But Jo then emphasized the importance of leadership in resolving those complicated interactions:

Leadership is crucial in achieving results and how we work on a unit.

And Hélène explained,

To prevent indifference, an equal dialogue with respect and trust is necessary, between a manager displaying serving leadership and the employee.

Izaak expanded on this, saying:

I think there are lots of initiatives that show the enthusiasm of staff to improve quality and safety. Sometimes the enthusiasm gets lost because of the lack of empowerment by the management. We forget to celebrate the success in improvements that are made on the initiative of staff members.  This gets back to them as lack of interest from the management in their efforts.

The answers are an important reminder that the introduction and dissemination of the Lean philosophy--or other any approach to improving quality, safety, and efficiency--requires leadership attention to the nature of how people learn and improve.  Our goal is to create a learning organization, to be "good at getting better" in the face of exogenous and endogenous challenges.  Leaders must have sufficient empathy to respond appropriately as the staff goes through the stages of learning--interest, distress, and pleasure.  If leaders are not attuned these stages, the staff will not learn the right lessons.  Then, we will be reminded me of Master Miyagi's statement in The Karate Kid: "No such thing as bad student, only bad teacher."

It is not the fault of well-intentioned and dedicated staff if they do not learn the aspects of process improvement that can transform a hospital: It is a failure of leadership.  As set forth by the great basketball coach, John Wooden, "You haven't taught them if they haven't learned."