How complex systems fail

Many thanks to Tim O'Reilly @timoreilly for sending me this thoughtful piece by Richard I. Cook, MD, from the Cognitive Technologies Laboratory at the University of Chicago.  It is a pithy article with a long title:  "How Complex Systems Fail (Being a Short Treatise on the Nature of Failure; How Failure is Evaluated; How Failure is Attributed to Proximate Cause; and the Resulting New Understanding of Patient Safety)."

Some excerpts follow.  If you are not careful, you can quickly fall into a terribly pessimistic view of the potential to improve quality and safety in clinical settings.  But if you think about it a bit more, you can see that having a "learning organization," one that constantly strives to be very good at getting better, is the best answer we have.

Complex systems contain changing mixtures of failures latent within them.
The complexity of these systems makes it impossible for them to run without multiple flaws being present. Because these are individually insufficient to cause failure they are regarded as minor factors during operations. Eradication of all latent failures is limited primarily by economic cost but also because it is difficult before the fact to see how such failures might contribute to an accident. The failures change constantly because of changing technology, work organization, and efforts to eradicate failures.

Complex systems run in degraded mode.
A corollary to the preceding point is that complex systems run as broken systems. The system continues to function because it contains so many redundancies and because people can make it function, despite the presence of many flaws. After accident reviews nearly always note that the system has a history of prior ‘proto-accidents’ that nearly generated catastrophe. Arguments that these degraded conditions should have been recognized before the overt accident are usually predicated on naïve notions of system performance. System operations are dynamic, with components (organizational, human, technical) failing and being replaced continuously.

Post-accident attribution accident to a ‘root cause’ is fundamentally wrong.
Because overt failure requires multiple faults, there is no isolated ‘cause’ of an accident. There are multiple contributors to accidents. Each of these is necessary insufficient in itself to create an accident. Only jointly are these causes sufficient to create an accident. Indeed, it is the linking of these causes together that creates the circumstances required for the accident. Thus, no isolation of the ‘root cause’ of an accident is possible. The
evaluations based on such reasoning as ‘root cause’ do not reflect a technical understanding of the nature of failure but rather the social, cultural need to blame specific, localized forces or events for outcomes.

Hindsight biases post-accident assessments of human performance.
Knowledge of the outcome makes it seem that events leading to the outcome should have appeared more salient to practitioners at the time than was actually the case. This means that ex post facto accident analysis of human performance is inaccurate. The outcome knowledge poisons the ability of after-accident observers to recreate the view of practitioners before the accident of those same factors. It seems that practitioners “should have known” that the factors would “inevitably” lead to an accident. Hindsight bias remains the primary obstacle to accident investigation, especially when expert human performance is involved.

Failure free operations require experience with failure.
Recognizing hazard and successfully manipulating system operations to remain inside the tolerable performance boundaries requires intimate contact with failure. More robust system performance is likely to arise in systems where operators can discern the “edge of the envelope”. This is where system performance begins to deteriorate, becomes difficult to predict, or cannot be readily recovered. In intrinsically hazardous systems, operators are expected to encounter and appreciate hazards in ways that lead to overall performance that is desirable. Improved safety depends on providing operators with calibrated views of the hazards. It also depends on providing calibration about how their actions move system performance towards or away from the edge of the envelope.

WWAD? (A=Atul)

The sad story of Rory Staunton, the young boy who died of sepsis infection, has been prompting a lot of commentary.  I have noticed that is the nature of press coverage that it often takes a sympathetic figure to get attention to a long-term, systemic problem in the health care system.  I have written here of the efforts of Dr. Jim O'Brien and others at the Sepsis Alliance to help doctors and nurses learn of the early warning signs of a sepsis infection.  Let's hope that the recent story will give a greater impetus to the expansion of training about this important clinical problem.

But it is not of that topic that I write today.  Instead, I would like to explore the obligation of the dominant health care provider in the region to become a force in reducing harm and improving quality and safety in its own institutions and beyond.  I am prompted to do so by a banner advertisement that accompanied Maureen Dowd's story today about Rory Staunton.  Here's the ad:

When you see an ad like this accompanying such a sad story, you are tempted to click through to actually see how "Partners is changing health care for the better" with regard to the types of issues elicited in the story.  What do we find?

Well, not much about the topic at hand.  While some other stories are included, a pervasive theme seems to be about cost.  Also, part of the messaging is meant to undermine reports done by the state's Attorney General about the disproportionate level of rates received by this provider group:

I don't mean any of this to suggest that this provider group is not trying to provide excellent care.  I know many of its doctors and nurses and have found them to be impressive and well intentioned people.  It just seems that this provider system is so intent on messaging for political purposes that we don't get to learn what they have done about the kind of misdiagnosis and mistreatment seen in the Staunton case, or for that matter what they have done to eliminate harm in other settings.  After all, there are many impressive and well intentioned clinicians throughout the United States who still collectively represent the fourth or fifth ranked public health hazard in the country.

I have noticed that the media in this city gives this provider group a bye on these issues.  Perhaps the reporters are so busy covering legislative debates on cost issues that they don't have time or inclination to see what's being done--or not being done--to stop killing and maiming patients.

So, here's my suggestion to enterprising reporters.  Let's consider who in Boston is most associated by the public at large with ideas for improving the quality of care.  Among that group is clearly Dr. Atul Gawande, a physician in this very provider organization, who has done superb work in this field.   A reporter might compile a list of  the major conclusions in Atul's books and articles. Then, the reporter could take Atul's recommendations for improving the quality of care delivery and see the extent to which they have been adopted by his hospital and by the entire health care provider network in which he works.

Several years ago, I noted:

The Partners hospitals are full of well intentioned, dedicated people. But there has not been a corporate public commitment to reduction of harm and to transparency of clinical outcomes that could help build broad public confidence in the quality and safety of patient care.... Ironically, some of the world experts in these matters are faculty members in his hospitals. The Partners system should be a world leader in the science of health care delivery, along with the fields in which it already holds prominence.

I'm not saying all of Atul's ideas are necessarily the right ones for all organizations, but should not the major provider group be held accountable to show how they have implemented his ideas, or if not, why they have not?  Who knows?  There might be some good news on this front worthy of publicity.  If so, perhaps future banner ads will click through to more relevant success stories.

Klepper makes the payment case clear

This is a very important article by Brian Klepper on Medscape.  It is entitled: "Will Anyone Listen When Former CMS Chiefs Call For More Objective Physician Payment?"  Pay particular attention to the parts about the committee that establishes the relative rates paid by Medicare to different kinds of specialists, a formula that affects virtually all private insurance companies as well.

There was a general sense that the RBRVS system was built on a series of errors, and that CMS' relationship with the RUC started off, to use Dr. Wilensky's term, "innocently enough," but has become increasingly problematic over time.

Tom Scully, CMS' Administrator under George W. Bush, took responsibility for helping facilitate the AMA's involvement and was perhaps the most passionate that it had been an error.

One of the biggest mistakes we made ... is that we took the RUC...back in 1992 and gave it to the AMA. ...It's very, very politicized. I think that was a big mistake...When you go back to restructuring this, you should try to make it less political and more independent.

I've watched the RUC for years. It's incredibly political, and it's just human nature...the specialists that spend more money and have more time have a bigger impact...So it's really, it's all about political representation, and the AMA does a good job, given what they are, but they're a political body of specialty groups, and they're just not, in my opinion, objective enough. So when you look at the history of it, CMS is starting to push back more, which is a good thing, I think it would be much better to have an arms-length transaction where the physician groups have a little more of an objective approach to it. And, look, that is the infrastructure of $80 billion of spending. It's not a small matter. It's huge.

But perhaps the most striking statement was made by Bruce Vladeck, HCFA Administrator during the Clinton Administration. In speaking about the problems generated by RBRVS (and by inference, the broader issues of SGR and the RUC as well) in the face of severe economic stresses, he called for the leadership and will required to simply do the necessary course correction.

I'm hopeful that some combination of the need to address overall deficit reduction strategies more generally and a different kind of political climate in the relatively near future will create the opportunity for people to say, "We made a mistake in 1997. We created a formula that produces irrational and counterintuitive results, and we're just going to abolish it and start all over again in terms of some kind of cap on Part B payments. It's the only way we're going to get out of this morass."

In a policy environment less susceptible to influence and more responsive to real world problems, the gravity of consensus on display at this roundtable would justify a call to action. As it was, it validated what many know: that we are rushing headlong down a catastrophic path, steered by forces other than reason and responsibility. The best we can hope for is that someone with authority and courage is listening.

Kate Spencer's new friends in India

My friend Katherine Spencer, Notre Dame class of 2014 (sociology and pre-health studies), is spending several weeks volunteering in and around Kancheepuram, India this summer.  She writes, "These two women wanted their picture taken so they can be famous in the United States. I promised to show it to as many people as possible."  I asked her for more of the story in return for spreading the images far and wide!  Here it is:

These women are part of the Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA). It is an act that aimed to eradicate rural poverty by providing eligible people (below the poverty line) with manual labor for minimum wage. The project we visited was in a village that was renewing a Kai Rassi clinic with this NGO, Hand in Hand.

A Kai Raasi clinic takes place once a week or once every two weeks and provides basic healthcare and medicines to the people. They are required to pay 20 India Rupees (less than a dollar!) and they see a qualified doctor. The doctor often gives them referrals to go to government hospitals if needed and Hand in Hand workers ensure that they get there. Hand in Hand supplies the clinics with medicines like soft pain killers and anti-diarrheals.

The workers were very excited--as was the local government leader--to be renewing the clinic. Here is the link to the Wikipedia page on the government scheme. I'll point your attention to the criticisms section, as it is very interesting. During this particular visit, one of the Hand in Hand Workers, Ms. Rajeswari, was counseling the women on causes, symptoms and consequences of anemia. Anemia is a huge problem here. She educated them about iron tablets they should be taking and foods they can be eating to raise their iron levels.

Here's a picture from another work site we visited.  There are a lot of awareness programs going on through Hand in Hand, and they aim to educate villagers on their health rights and major health issues. In this particular one, we talked about loans they can be given to construct toilets and renovating local Anganwadi centers that act as day care for village children. They are given a nutritional lunch while attending, aiming to eradicate malnutrition.

An interest in remaining alive

A coda to my visit to Israel was an article from the newspaper Haaretz that I read in the airplane as I flew off.  It was by Aner Shalev and was entitled, "We have an interest in remaining alive." 

Here's the lede:

The Carmel fire, the 1997 helicopter disaster, the Second Lebanon War, the Yom Kippur War -- this year we had an even greater disaster, but no commission of inquiry looked into it.  In this year's disaster, we lost more people than in those two wars together.  It's an ongoing battle that claims about 4,000 casualties every year, according to official figures that have probably been toned down. We lose this battle time and again -- but it seems nobody cares.  Israel's hospitals, which are supposed to save us from illness and injury, have turned into our worst killing fields.

Most of the article deals with MRSA and other hospital-acquired infections. But then there is the complaint about a lack of transparency:

On top of this, the Health Ministry has statistics about infections at our hospitals.  The ministry published these figures recently, without mentioning the hospitals' names.  The pressure to publish this vital information was warded off with the strange claim that it wasn't of public interest.

Israel has a marvelous, universal public health system of which it should be justly proud.  But like every other developed country, Israel has a problem with the amount of harm -- mortality and morbidity -- caused by its hospitals.  I don't know if this author is correct that the amount of preventable harm is under-reported, but I do know something we have learned throughout the world:  If there is not a clear presentation of the degree of harm that exists in each hospital, there will not be and cannot be an effective effort to reduce it.

Lean stories at Hadassah Mt. Scopus

Jim Womack and I changed venues in our Lean mission today, moving from the main campus of the Hadassah Medical Organization in Ein Kerem, Jerusalem, to the smaller (300-bed) community academic hospital at Mt. Scopus.  This was the original Hadassah hospital, abandoned in 1948 after several dozen staff members, including the director-general, were massacred on their way to work.  It re-opened in the 1960s, but after planning and construction for the new large hospital had occurred.  It serves a mixed Jewish and Arab clientele, and its staff also reflects that mixture.  The building is lovely -- old-fashioned and warm -- as are the people working in it.

We started with a quick gemba walk.  Here Jim is seen with emergency department chief Ruth Stalnikovitz and hospital director-general Osnat Levztion-Korach -- historical note, formerly known as just a regular doctor!)  Then it was off to a general assembly with staff about the nature of the Lean philosophy.  Jim pointed out that, properly executed, it can lead to better patient outcomes, a better patient experience, a better staff experience, and not coincidentally, lower costs.  The last is true because many activities that lead to bad outcomes, and poor patient and staff experience, add cost.

I then provided examples from BIDMC, including a dramatic improvement in the patient experience in the orthopaedic clinic and improved viability of blood samples from the emergency department.  I added some thoughts about the importance of transparency in an organization that wishes to hold itself accountable to the standard of care to which it aspires.

Jim and I both left with the feeling that the Mt. Scopus hospital has tremendous potential to benefit from the Lean philosophy and hoping that the leadership and staff of the hospital will choose to embrace it.

Please support The Waiting Room

One of the more worthy projects over at Kickstarter is The Waiting Room -- What are you waiting for?  This is a moving and important video produced by Peter Nicks and his colleagues about people in an Oakland hospital waiting for and delivering care.  Pete notes, "It's an unfiltered view of patients and caregivers at one public hospital that allows the audience to experience and feel one part of our health care system in a way films rarely do: by placing the voices of patients and caregivers firmly up on stage."

He explains:

From the very beginning, this project has been about giving a voice to the millions of people that lack health care insurance. But it is also very personal for me. The Waiting Room developed from stories my wife, a speech pathologist at Highland Hospital, told me about the struggles and resilience of her patient population. And a few years ago, as the contentious vote for health care reform got louder, it occurred to me that the people who were not participating in the debate were the very people we were fighting over: those stuck in waiting rooms at underfunded public hospitals all over the country.

As the film is independently produced, the Kickstarter campaign is to raise money to launch a grass roots and community outreach initiative to support its release in the fall.  Pete explains, "The more successful these initial openings are, the wider we can expand across the country, bringing the film to more and more people."

The film has gotten excellent reviews and deserves to be seen broadly.  Please support it here.  But do it soon, as there are only a few days left in the Kickstarter campaign.

Canadian harm dollars add up, too

In my speeches and presentations in front of US audiences, I often make mention of the financial cost, as well as the human cost, of preventable harm in hospitals.  When abroad, I assert that the level of harm is roughly proportional to the population of the particular country.  This is irrespective of the institutional scheme of funding health care -- nationalized, private payer, public payer, single payer, multiple payers.  Such is the case because the systemic determinants of harm are related to the training received by medical providers and to the design of work associated with care delivery in hospitals, which are remarkably similar throughout the developed world.

We can extrapolate levels of preventable to the unnecessary costs incurred by such harm.  This point is documented in a recent publication of the Canadian Patient Safety Institute, summarized in this article.  An excerpt:

In the release of the paper ,"The Economics of Patient Safety in Acute Care," researchers have calculated an estimated economic burden of preventable patient safety incidents in acute care in Canada for 2009 - 2010 to be $396,633,936 ($397 million).  This estimate is only a small portion of the estimated entire cost of harmful incidents, and it does not include the indirect costs of care after hospital discharge, or societal costs of illness such as loss of functional status or occupational productivity.

Getting past "kacha zeh" at Hadassah

Jim Womack and I continued our Lean mission today at the main campus of the Hadassah Medical Organization in Ein Kerem, Jerusalem.  We started with a gemba walk through the emergency department and then up to the internal medicine wards.  I had seen these areas a couple of days ago, but Jim has just arrived.  As always, he asked great questions and had thoughtful observations, particularly about the problem of patient boarding in the ED.

Later, we both participated in a hospital-wide session organized by CEO Ehud Kokia.  His purpose was to provide the staff with an overview of the purpose of the Lean journey and also to offer progress reports on some of the process improvement work that has been occurring to date.  Jim and I were then asked to provide our view of the Lean philosophy and its chance for success at Hadassah.  Jim was characteristically blunt, noting that he had reached a diagnosis -- a hospital characterized by a traditional management system -- a prescription -- a hospital in which both horizontal management and vertical management would exist to support cross-functional process improvement.  But he demurred on the prognosis, saying it was too soon to tell.  Quoting Henry Ford (an irony in light of that person's creation of the dehumanized assembly line model), he said, "It depends on you.  "Whether you think you can or you think you can't -- you're right.'"

My talk followed with some stories from our Lean experience at BIDMC, with (no surprise to this group of readers) analogies to soccer.  Picking up on Jim's conclusion, I suggested that a sign of success at Hadassah would be the elimination from conversations of two words that suggest defeatism and acceptance of the status quo, kacha zeh, "It is what it is."

How do you say "Lean" in Hebrew? "Lean."

Boaz Tamir of Israel Lean Enterprise has created a "Lean Club" comprising a small group of Israeli corporations and institutions who get together four times a year to share experiences, problems and success as they undergo their Lean journeys.  The group includes senior level executives from banking, insurance, food processing, high-tech, and health care.  Because the firms are all at different stages of Lean adoption, the diversity of viewpoints is stimulating and valuable to all.

Boaz started today's session with a reminder about the differences between traditional managerial approaches and that envisioned in a Lean organization.  The slide shown here presents a quick summary.  Boaz stressed that changes in the world economy would be filtering through to these businesses in Israel and suggested that Lean principles could help companies survive and thrive in the face of an avalanche of difficult events.

Today's special guests included Jim Womack, acknowledged world expert in the field.  Jim has a way with words, spinning out stories and theories about Lean and non-Lean organizations.  Both entertaining and informative, he makes it easy to learn.  He reminded the group that a firm needs to be clear about its purpose, but that this needs to be thought about from the customer's point of view.  He noted the schizophrenia we all exhibit -- being providers and producers in our corporate roles, but immediately flipping over to consumers when we go home from work.

Jim drew some comparisons between the desires of the two groups.  For examples, customers want transparency about the cost and quality of goods and services.  Businesses have often relied on opacity in selling their products and services.

He reminded those in the room, "All of you are mature businesses," and so your assets are threatened by changes in the marketplace.  "You think of how you can protect your undepreciated assets, but your consumers want something new."  Thus, "there is a disconnect between customers' and companies' valuation of assets."

Jim said, "This is part of life."  Firms need to adjust to the fact that the frequency of the need to re-evaluate customers' needs is accelerating.

But, he noted, "It is not just assets that are threatened.  It is your processes."  He pointed out that traditional corporate folks who conduct process evaluation often do not think about customers.  They often pursue enhancement to processes that don't bring value to customers.

He reminded us that "all processes involve people."  Therefore it can be threatening and frightening to people in a firm when process design is coming.  The irony, though, "is that you can't develop new processes without people."  Hearkening back to Boaz's points, he said that it takes a different kind of management to work in a Lean way.  Unfortunately, he noted, "management thinking is often impoverished."

These were sobering thoughts, even for this group of executives who are committed to Lean, but the group had an upbeat attitude and took Jim's comments in stride as they engaged in collaborative learning during the session, sharing stories and challenges from their own experiences.

First Lean steps in Jerusalem

I spent the day at the main campus of the Hadassah Medical Organization today in Ein Kerem, Jerusalem, with staff members engaged in learning about and experimenting with Lean process improvement.  I think the hardest thing for people to accept about Lean is that it is a philosophy based on incremental steps rather than major revamping of complex systems.  The idea is that small advances lead to great gains over time.  Your front-line staff encounter a problem in the workplace and then you design an experiment to try to solve the problem.  Then you evaluate the effectiveness of the experiment and, if necessary, redesign it.  If it works, the new "current state" becomes the basis on which you then try to move to yet another improved "future state."  The process never ends.

Every hospital I have ever visited has a problem discharging patients in a timely manner, and Hadassah is no exception.  This is an important problem to fix for obvious reasons, but there is a not-so-obvious reason as well:  When patients do not leave the wards, it creates a back-up in the emergency department.  Patients find themselves spending hours awaiting a room upstairs.

On one internal medicine ward, Murielle Cohen, the chief nurse, and Professor Dror Mevorah, the chief attending physician, are testing out a simple experiment, whether a white board listing all patients possibly eligible for discharge, along with each step required in the discharge process, might facilitate communication between the nursing staff and the doctors and others to move things along.  During my tour today, they were joined by Chana Tsurel, manager of the internal medicine department, and Pnina Sharon, head nurse of the ER, both of whom have been working to improve communication between the two departments.

In the eye clinic, another approach was taken by head nurse Sigalit Cohen and her physician and technician colleagues.  They faced a problem of long waiting times because a certain injection procedure was batched once per day.  By adding a second session, they were able to improve the flow of patients through the clinic.

Both of these examples are small steps forward in a big hospital that has not yet become fully engaged with Lean.  But they offer the possibility of confidence building measures that will help persuade doctors and nurses that there is potential for broader improvement if people make the commitment to Lean principles.

You don't "do Lean"

If there were a form of medical malpractice lawsuit that I would like to encourage, it would be against those consulting firms that promise hospitals that they will teach them how to "do Lean."  I recently encountered a hospital in which a well known international consulting firm did it this way:  Assemble 25 top level managers for a week-long off-site seminar, teaching them all the Lean terminology and getting them ready to do Lean projects.  Then keep one or two of your consultants in residence for a few months to provide aid and comfort to the managers as they attempt to run rapid improvement events in areas of the hospital chosen by somebody as "high priority" areas needing cost savings.  Then leave behind your "trained" cadre of managers to carry on -- which they cannot or will not do.  Charge the hospital several hundred thousand dollars for this "service."  But not before you have given Lean a bad name and, worse, have caused it to be associated with layoffs (or redundancies, as they say in the UK.)

I'd like to explain all the things wrong with this, but I would just get upset.  Let me provide the simple explanation.  You don't "do Lean."  Lean is not a program.  It is a long-term philosophy of corporate leadership and organization that is based, above all, on respect shown to front-line staff.  There are two essential aspects, training front-line workers to be empowered and encouraged to call out problems on the "factory floor," and training managers to understand that their job is to serve those front-line workers by knowing what is going on on the front lines and responding in real time (when problems are fresh) to the call-outs.  Yes, there are all kinds of methods and tools and terminology, and as Virginia Mason Medical Center's Sarah Patterson notes, "Lean provides a common language for process improvement." She also reminded us, though, that it is a focus on process, not on the outcomes.  The idea is to "build key features into processes that are waste free, continuous flow."  To do this we need to "grow leaders-- to respect, develop, and challenge your people."

I hope that those of you who have been following my commentary about our Lean workshops at Ipswich Hospital NHS Trust will have seen an emphasis on these points.  You will have also seen that we employed on a pedagogical approach that relied heavily on going to gemba.  You cannot teach respect for front-line staff by sticking people in an off-site conference facility for a week.  You cannot teach people to notice the problems in work flows if they are not looking at the work flows.  You cannot teach the principles of incremental improvement and experimentation if you direct managers and staff to spend all their "Lean time" on time-consuming projects in "priority areas."

Jim Craig (seen here shadowing a person during the workshop) told me this story after we were done.  He was walking through a ward and heard a trainee grumbling about something.  He went up to her and said, in a friendly way, "I happen to overhear that you were upset about something.  Would you mind telling me what it was?"  The answer was that, many times per day, the resident would need to print out a form from the computer.  But the ward was a large ward, and the one printer was at the extreme end of the floor.  So, when she was seeing patients at one end of the floor, the resident would have to spend 5 minutes each time walking across the floor and back as she collected the form.  Jim said, "Would it help to have a printer at each end of the floor?"  "Oh, yes," was the reply.  Then and there, he called the IT department to arrange a printer to be delivered.  Result: A very grateful trainee, who will now have more time to be with patients rather than fetching papers.

The Lean aficionados out there are already fidgeting, for they have noticed other potential solutions to this problem.  And they are asking questions like, "What is the form itself, and does its production add value."  Those would be good things to explore.  The lesson, though, is that Jim was at gemba, heard the (unintentional) call-out, responded respectfully, and analyzed and solved the problem while it was fresh.  I give him an A+ for demonstrating what he learned at the workshop.  Well, let's make it an A- so he knows there is always the potential to improve!

Heather helps us all

Please check out this thoughtful blog post by Heather Thiessen, a patient I met a few months back in Saskatoon.  She tells her own story well and has some good thoughts for both providers and patients.  Excerpts:

Living with two chronic — and sometimes critical – neurological conditions made me realize that I had to start standing up and being an active partner with my health care team. No one else would be there to tell my side of the story or speak up for what I really wanted to do when my condition worsened or when it was time to explore new ways to get me back to my normal status.

The next chapter in my journey as a patient began when I was invited to be part of a patient panel for the Patient, Client and Family Centered Care Workshop in October 2010. This was a very emotional event for me, because I had to share some of my worst care experiences with many of the people who had cared for me. But I felt that doing this was an important part of my being able to be an advisor. Many of those who heard my stories came up to me afterwards and told me they too remembered the events and were so sorry for the pain I felt. This was a learning event not only for me but for them as well. After this, I was asked to be a patient advisor in both the Neurology and Rehab departments and the ICUs in Saskatoon.

Is it scary being involved in these advisory boards? Absolutely! But when I see all the wonderful things that can come out of this work, I am happy that I’m involved and I’m happy when new families and patients join. I deeply care for those who have saved my life so many times. But health care, like most things, is not all rosy. If I can help make things better for staff, then I know things will be better for me and other patients.

Blogging feels like the next step in my evolution as a professional patient. I see it as a way to help bring the voice and perspective of patients and families to an even wider audience, to become part of a larger dialogue about making health care better. 

Trusting myself and listening to my inner voice has helped make me a better partner in my own care and get the best possible care possible. I hope that my stories and experiences resonate with others – not only patients and families – but also people managing and delivering health care.

Cross-cultural good luck

On Uxbridge Road in London, using good luck symbols from different cultures.  Hey, it can't hurt!

An eye clinic helps us see Lean more clearly

One of the lovely aspects of Lean that we discussed during this week's training workshops at Ipswich Hospital was the concept of kaizen, process improvement accomplished by incremental change.  I often add another characteristic to the approach:  Can we achieve an improvement with no incremental cost?  Strictly speaking, that cost constraint is not part of Lean.  After all, sometimes you have to make an investment in personnel or equipment, and it often has an excellent return to consumers, the firm, or both.  But I have found that asking people to think about how to change things at no cost opens up floodgates of creativity.

Here's an example from our discussions.  Ipswich Hospital operates an eye clinic and has an open access policy, i.e., you do not need an appointment.  The open hours are from 9am to 1pm, and then from 2pm to 5pm.  The idea of open access is terrific: More and more organizations have employed it.

What happens here, though, is not quite terrific.  A patient goes to a GP and is told that s/he needs an eye exam or other treatment.  S/he shows up the next day at 9am, only to discover that the people referred by any number of the several dozen GPs have also decided to go first thing in the morning.  The staff cannot handle this huge batch of people, and many are left waiting for two or more hours to be seen.  These are often elderly people with vision problems, and so you can imagine the discomfort and, ultimately, the frustration and anger that result.  Also, as word has gotten out about this problem, people have started to show up even earlier, at 8:30, in the hope of getting to the head of the queue. It feels like a case of "no good deed going unpunished," but it is actually a classic case of batch processing when what is desired is a flow.

When this scenario was presented to our class, I asked them to invent an improvement with which we could experiment that might alleviate the problem.  How do we transform the batch to a flow, to match the consumers' needs with the resources available in the clinic?  People immediately started by adding steps to the process:  Perhaps GPs would have pre-printed chits, with different times of day, that would be handed to patients.  (But how would we coordinate the chits across all of the GPs, with changing numbers of patients every day?)  Perhaps the staff in the GPs' offices could call ahead and see how busy the clinic was.  (But then we would add to their work and would also be interrupting the people working in the clinic.)  Perhaps we could install a computer system that would post on a website the number of people waiting at the clinic and the expected delay in appointments.  (But then we have to pay for that system and have someone at the clinic enter the information throughout the day.)

I then asked the group to consider a process that would involve no new steps and add no costs.  The answer emerged:  Make it clear with a simple one-time message to GPs and a poster on the clinic entrance that the clinic would prefer (but not require) that people whose surnames began with "A" to "F" would be welcome at 9am; "G" to "M" at 10am; and so on.  "Ah!," said the person who had mentioned this problem, "So simple.  Let's try it."

Ipswich leaders offer next steps on Lean

As we ended our Lean training workshops at Ipswich Hospital NHS Trust, I asked the participants to send me an email indicating what concrete steps or actions they would take in the next week to practice or implement some of the principles we had discussed.  Understand that I was not asking for a full implementation of the Lean philosophy in the hospital:  That requires a huge commitment at all levels of the organization and is something not lightly entered into.  Rather, I suggested that the basic principles of Lean can be practiced by managers and leaders at any time.  Quoting Don Berwick's line that "soon is not a time," I suggested that if you don't actually begin to practice those principles, they are easily left aside during day-to-day activities.  Here are some responses, with names omitted:

-- I think we do not do enough of this, that is the reflecting on the work we do and how we do it. There have been a few gems over these events, but one for me to highlight was the response that I did not get time to write after the second day of the course, when I was going to tell you how much I hated my office. It’s actually a nice room, light, airy, and well located, but I’m in it too much, and that’s why I don’t like it. The trip we had to stores was an important reminder for me to get out and about more – and I have now scheduled time in my weekly diary to do just this. In my own unit we have initiated a new ideas scheme, and I think this is a good practice, but your element of calling out issues, build on that even more, and I am now thinking about how we can recognise and encourage such behaviour. It’s funny that last night I realised that one of our excellent middle grades in the Oral department has called out just recently, pointing out an important issue with our outcome forms that we are now resolving. I intend to write about this in my next newsletter.

-- You might have already worked out the NHS problems such as long waiting period for clinic appointment, long waiting list for routine surgical operations, failure to meet targets,  ineffective utilization of theatre and some of the staffing issues in the department. I observed the measures the management teams are taking and miserably failing to sort out the problem or fixing it temporarily and finding them in the same situation again. I do not have any management training, but I try to put myself in a mangers position and think. Often, I think if they try a certain approach it could work. As a clinician, being in similar situation at other hospitals and seen different management strategies which work, I wish I could shout out my ideas and open a dialogue, eventually solve the crisis. But often people in management or power don't listen. I feel embarrassed and often apprehensive as how others take your opinion. Also, I do not want to offend my colleagues and consultants with ideas which will direct implication on them.  I sincerely hope this Lean workshop will help Ipswich Hospital to work out the areas which needs careful management intervention.

-- I will use every opportunity to visit the shop floor and in doing so change my approach to one of observation and learning. I will start referring to little changes that I have made each week when I meet with my senior team, and I will begin to ask them the same so that we can all learn from our changes and how these have been achieved.

-- In the next few weeks I want to implement a number of small projects implementing the Lean principles. These include looking at the way my colleague and I process colorectal referrals, which currently come to us in batches and take ages to work through, with the resultant work being delivered to the secretary all in one go. I am sure we can turn this into a continuous work flow.

This morning, I saw in the store room, theatre gowns, which I was told had stopped being ordered. They prevent my forearms being covered in blood after long abdominal and pelvic surgery. I will speak to the relevant people to ensure they are delivered to theatres on a regular basis. 

-- I have long thought that Lean is a system that we must embrace. I have read often of the benefits of its application in healthcare. However from your tutelage I now understand that it is a methodology first and foremost to improve the quality of care we give our patients. Any financial benefits are as a result of this ‘the virtuous relationship between quality and finance’ as you put it.  I think this fact is lost often in translation (the pun is intended!) and certainly has been an impediment to its dissemination in healthcare in the Ipswich.

It is my hope that as a result of your visit we now have a nidus of colleagues who have seen the huge potential of working in this way. I will try to bring us together, initially informally, once a fortnight to share our experiences and our successes. I am going to suggest that we each try to cascade Lean to one other individual every month and so on and so forth (a bit like Amway!). In time incrementally we will develop a philosophy across our shop floor of continuous improvements.  From our group we will identify someone to receive more comprehensive training to become our Lean coordinator or sensei.

-- I believe that the changes we make have to be sustainable. Small changes will make a difference. As an organisation facing many challenges, we must ensure we do not waste energy by repeating processes that do not work.

My mission will be to engender a 'can do ' attitude.I will challenge any negativity from staff, and  I will challenge myself to ensure I have the systems in place to allow all my staff the opportunity to contribute ideas and comments. I will work with my team leaders to action these.

I will challenge myself to visit areas in the Hospital I am unfamiliar with, in relation to the patient pathways and processes that affect patients who are cared for in my areas. This will help me understand the real experience the patient has and allow me to examine ways to improve the systems.

I will also invest some time to reorganise my office to improve my access to information etc!

-- Pledge to spend 1 hour a week with a colleague observing work with an aim to make improvements to their working life. And do this with respect for a co-worker who knows more about their job than I (as a manager) will ever know. Then ask that person to do the same for 1 of their colleagues to rapidly spread lean principles across the organisation.

-- After an energised afternoon looking at the 5S, I and my other 'Lean' colleagues returned to our offices. At least four of these colleagues took this opportunity to check their inbox. As responses hit my inbox during the time I sat also responding to emails. I asked myself 'Is email the best way to communicate this message?'

There must be alternative ways of conveying a message. I plan to involve staff by asking them to discuss the benefits and drawbacks of looking at other channels of communication

Could we consider a no email day? Why do we send an email when a face to face meeting or a phone call maybe more effective & even quicker than waiting for an email response.

Perhaps a coffee or lunch break with a group could be utilised to share information and we can encourage staff to think of alternative ways of communicating information.

I will review the types of information that I regularly send and receive. Many of them are to request information required on weekly or monthly. Instead of chasing on a weekly or monthly basis perhaps develop a timetable of the information required. 

My initial thoughts are that perhaps phone calls and face to face meetings could be more time consuming however as an organisation we need to make a real effort to reduce email overload and I believe this has the potential to ensure better teamwork, a quicker problem solving approach and a happier workforce.

-- Next week I plan to improve our ultrasound scanning service to inpatients.

At present, at the start of the day, all the pending inpatient ultrasound scan request forms are reviewed by the radiologist scheduled to perform the scans. This means there is a flurry of activity (batching of work) in the early morning with the radiologist sorting through a large pile of paper forms, the imaging assistant ringing the wards with instructions and writing out collection slips for the porters, the ward clerks receiving those instructions and passing on the information to the relevant nursing staff who in turn speak to their patients about what is about to happen. It is all a mini whirlwind as this needs to occur before the radiologist starts scanning the first patients on the list (who are outpatients arranged in advance - to prevent downtime whilst waiting for the first inpatient to arrive). 

The rush means it is stressful for all in the chain. For the imaging assistant it means time on the phone and liaising with the porters when she should be helping with the first (out)patients. On the ward other tasks are interrupted to prepare their patients to come down for their scan. Because of the short notice often the doctors on the ward rounds do not know that the scans have been scheduled and ring up to enquire if and when the scans will be performed thereby disturbing the radiologist who has to stop scanning the patient of the moment. Additionally, there is frequently inadequate time to get the necessary preparation right, e.g. the patient for a pelvic scan has an under filled bladder and the scan is inadequate or worse still needs to be repeated. Most importantly, the patient and their relatives, who have usually been told by their attending ward doctors that they need a scan, are anxiously waiting not knowing what is happening for longer. 

How can we make this better? 

One possible way would be to review all outstanding request forms at the end of each afternoon and schedule the scans for the next day. That way everyone knows well in advance and can be planned to fit in around other activities. Waste could be reduced. 

Can I persuade my colleagues to change? Will they come up with a better solution? Watch this space.

-- Have largely been doing this process for the last 7 years thus the result of a large well functioning AMU which is Nationally acclaimed for its results.  My steps now will be to insist other departments work with us in the same way to allow a smooth patient journey...first e mail has been met with horror so far!!

-- I am currently tidying my office!

Last week we had a crisis meeting about an inability to find slots for patients to have lung function tests. I now realise how we can make the situation better but using existing capacity in a smarter way. In the next week I intent to meet with our lung function unit manager to find a way of better matching his work load to the chest clinics. His team appear to run the same timetable every day even though the chest clinics are not evenly distributed.  Also, if I go on holiday, I don’t warn him that this is the case and so he can’t plan a different task for his technicians.  Given enough warning they could book more patients for routine tests on these days that don’t have to be coordinated with my clinic.

-- I have today agreed to mentor a colleague who works at a supervisory level in the Trust, meeting her once a fortnight to discuss the issues she faces, and help her to work through them.  I plan to share practical Lean principles during these sessions with her.

Whatever I am doing I will always watch, listen to and spend time with my teams to truly identify the root of problems/obstacles; working with the team to resolve them together – this is the crux of every manager’s job!

Ipswich pigs teach the value of standardization

Standardization, or reduction of variation, is a big part of the Lean philosophy, and that was our topic today during our training workshops at Ipswich Hospital NHS Trust.  To illustrate the value of standardization in helping to bring about consistent quality of output with less effort, we employed the pig exercise.  Regular readers are familiar with it.  You can see the first of the sequence of three blog posts describing it here.  In part one, participants are asked to draw a pig on a grid, following oral instructions.  In part two, written instructions are provided.  In part three, the written instructions are accompanied by a picture of the desired work product.

Fortunately for his patients, resident Satheesh Iype is a better surgeon than artist.  With good humor, he accepted the friendly ribbing of the entire group at his depiction of a rabbit -- or goat -- or pig.

By round three, all participants were able to produce an accurate and speedy rendition of the desired pig design.

On a more serious note, Sateesh offered the following thoughts after the workshops and particularly after spending time at gemba, shadowing and observing workers in the hospital:

I think my greatest achievement [from this week] is a change in attitude.  I am taking a positive attitude.  Over the last two days, I have been observing other employees of the Trust, i.e Darren, the X-ray porter, and Tom, the HSDU stock manager.  I respect them even more and understand the important role they are playing in the process.  I see things with a different perspective and will try to take every effort to cut down time wasting.

Supplying Ipswich Hospital

As we continued our Lean training workshops at Ipswich Hospital, we spent some time with Thomas, the young man who is in charge of the major receiving and distribution center for supplies entering the hospital.  Specifically, the HSDU ("hospital sterile and disinfection unit") storeroom contains medical devices and supplies and sterile equipment and packs for wards, departments and theatres (i.e., ORs).

All of the managers taking the workshop were tremendously impressed with Thomas -- his devotion to the health care mission of the hospital, his sense of initiative, and his strong sense of responsibility to the patients whose care depends on maintaining an adequate supply of mission-critical equipment.  And yet they also quickly came to understand that Thomas, in essence, is working with one hand tied behind his back, i.e., in an environment that is designed to be inefficient and wasteful.  In that regard, I told the group, he typifies many other inventory supply people in hospitals worldwide.

Thomas and his colleagues in many places live in a world in which they are put in the middle, receiving no visual cues as to incoming supplies from vendors and also no visual cues as to the demands of customers, the wards and ORs upstairs.  Some of his suppliers are reliable, but at least one is not, sending packages slowly and in deficient quantities.  On the demand side, if there is a surge in, say, OR utilization, he learns of it by a quicker depletion of his stocks.  He also has no idea how much inventory is being stored on the wards or, as here, in trolleys in the hallways outside the wards.

So Thomas does what you or I would do.  He plans conservatively, using rules of thumb that result in over-stocking of supplies.  After all, the last thing he would want to do is run short when a patient's life is at stake.  For example, knowing that one supplier is slow and unreliable, he over-orders from that supplier.  If he still runs short, he can pay extra for an emergency delivery.  In both instances, he is essentially rewarding the unreliable supplier.  Because Thomas is not in charge of the procurement process itself and has no influence with that department, it does not matter if he calls out this problem to a superior. 

The knowledge Thomas needs to do his job is essentially inside his head.  If he were to get sick and injured, there is no one else in the hospital with his abilities.  When he leaves for a two-week holiday, he pre-orders extra supplies for those two weeks.  "When I am on leave, I have to cover stock whilst I'm off."

The managers in our Lean workshop left with a greater appreciation for people like Thomas, but also with an understanding that their role as hospital leaders must evolve.  In a health care system facing ongoing cost pressures, the kind of inefficiency represented by the environment within which Thomas is working is unacceptable.  He should be given the tools he needs and the support he deserves to efficiently stock and deliver the millions of dollars of inventory needed for safe and effective patient care.  I believe that, whether or not Lean becomes a hospital-wide philosophy,  our team felt strongly a new sense of responsibility to take steps to adopt its principles in their own work environments.

Learning Lean in Ipswich

Today was the first of a series of workshops on the Lean process improvement philosophy at Ipswich Hospital, and I was pleased to meet two dozen people from various jobs around the hospital.  We started with an introduction based on the Toast Kaizen video produced by and featuring GBMP president Bruce Hamilton.  Then it was off to gemba, the "factory shop" floor, where the class members shadowed a member of the staff. The idea was to practice observation skills and try to identify the various types of waste found in all organizations.  (You see one example above, with a student watching the work done by the unit coordinator of one of the wards, and another below, observing a staff member keeping up with the status of his patients.)

The class members gained a new appreciation for the degree of difficulty faced by their colleagues in doing their everyday jobs.  They noticed impediments, inefficiencies, and work-arounds.  We listed these and posted them to compare the experiences from different areas of the hospital.  Later, I gave everyone a homework assignment, which was to answer the following question: 

Waste exists in Ipswich Hospital because the people who work here are uncaring and lazy. True or False? Provide evidence in support of your answer.

I suspected (and hoped!) that the answer would be "false," and it always was.  People understood that the well-intentioned and hard working people in the hospital face the common problems of complex organizations.  I promised to include the "best" answer here, but they were all excellent, so I have chosen a few a random.

Gary Picken wrote: 

False. I believe the large majority of staff at Ipswich Hospital are caring people who want to make a difference to patient's lives. Waste exists there because we are working in systems and with processes that are inefficient. These have often come about more by accident and the legacy of history, than by design and gathered evidence. The waste continues because we either do not see it or we feel impotent to effect change. Certainly, as clinicians in this organisation, we have not received the investment of the training for such leadership in the past. 

An example of waste:  An elderly man with lower limb arterial insufficiency referred to me for a femoral arteriogram, a procedure involving puncture of a large artery in the groin and an overnight stay in hospital.

Imagine, he has the worry of waiting for the 'test', the myriad of social arrangements to enable him to be there on the allotted day, his hospital bed and slot on the list are ring fenced so unavailable to anyone else.

He arrives in the angio suite after being admitted to the ward (time of ward clerk, nurse, junior doctor, porter) only to have his procedure cancelled because nobody has told him to stop taking his clopidegrel (strong blood thinning medication).

None of the staff wanted that outcome for him, just the opposite. The system had failed him. An ancient system that relied totally on the experienced medical secretary and faltered when she was absent, ill or made redundant.

That's where LEAN, I hope, can improve our hospital.

Jenna Ackerly noted:

The statement that waste exists at Ipswich Hospital because the people who work here are uncaring and lazy is false.  My experience in EAU today and from working in the hospital generally, proves this by constantly demonstrating dedicated, hard working and caring staff, going about their work in good humour.  Waste in fact exists because people are so busy going about their day jobs, in the same way they have always done (or been shown to do), that they fail to spot duplication, waste and inefficiency – or if they do, they feel that they do not have the responsibility to change it. 

Often new processes are introduced without explicit instruction that the old process can be dropped – thus creating confusion and duplication.  In my experience the only problem with our dedicated and caring workforce is that they work hard but not always smart, thus refuting that they are lazy or uncaring.

Jonathan Douse opined: 

Waste does exist at Ipswich Hospital but I don’t think it is because people are uncaring or lazy:

1)      I chose to work at Ipswich Hospital because it is a friendly place to work and because people generally say yes when I ask for their help.  If they say no it is because they have a good reason.

2)      When I walk down the corridor I see people directing the lost visitors and patients.

3)      My clinic receptionist is frustrated by her inability to get inefficient processes changed. 

4)      Many  of my colleagues work far more than their scheduled hours.

And Sam Bower offered this thought:

Waste exists because we do not dedicate the time to think about how to eliminate waste and improve process. For example the ward clerk redirecting all the mail today. She knew it was a problem as it "annoyed" her but when does she have an opportunity to tell someone it's a problem? She did today when I dedicated an hour of my time to observe her work. We need to do this more often. An hour a week with a colleague to identify waste and to embed the philosophy of lean thinking into our organisational culture. Not linked to finance, not linked to targets, but linked to improving the working lives of staff and improving morale.

Lessons from a taxi driver

I took the train from Ipswich to London this weekend for a break between my first and second week of lectures and workshops at Ipswich Hospital.  En route to the train station, I received a running (and unsolicited) commentary from my taxi driver.  As we drove by the hospital, she gave me her idea for process improvement there (knowing nothing about my background or purpose for being in Ipswich.)  It was something like this:

My mother was in the hospital a while back and I noticed, when picking her up to leave, that patients often sat in their rooms for 4 or 5 hours waiting to be discharged.  They were all set to go but just needed some test result or medication.

What a waste!  Those rooms could be used for someone else.  All it would take would be to have the hospital electrician -- who is on the grounds anyway -- to string a wire for an emergency buzzer, and buy a few easy-chairs for a couple of hundred pounds.  Then they could wait there comfortably and free up beds for others.

Well, I took it upon myself to write to the Chief Executive.  I didn't get a reply but I noticed in the newspaper a week or two later that the hospital had decided to create a new discharge lounge, ad so I felt like someone had actually listened to me.

But then I learned that instead of just stringing a wire and buying a couple of easy-chairs, they had spent a ton of money on building a whole new section and hiring nurses and nursing assistants to staff them.  I guess when you have other people's money to spend, you are likely to spend more!

I am guessing that it was regulatory requirements rather than a desire to spend other people's money that led to the hospital's design and staffing decision on this matter.  After all, until a patient is formally discharged, s/he is still a total responsibility of the hospital.  I would have explained this, but my voluble taxi driver was already on to the next topic.

But the story reminded me again about the interest that family members and patients have in being helpful to their local hospital.  They might not always have enough knowledge of all aspects to correctly frame the solution, but they have good instincts and perspectives on how the care environment might be improved.  (See this example from my former hospital's ICUs.)

It behooves all hospitals to create a process by which well-intentioned and thoughtful constituents can be heard and integrated into the clinical care process and setting.