Thursday, January 31, 2008

Organizational wiki

This is a request for advice. As I have noted below, we are engaged in a major process improvement and staff engagement process we now call BIDMC SPIRIT. We are designing a system that will enable staff people throughout the hospital to call out problems that they see while doing their everyday work, and then have help teams focus in on those problems, do root-cause analyses, and construct sensible solutions and diffuse them throughout the organization. This process, in part, relies on experience from Toyota, but it also uses some newer work done by other organizations.

Our folks are excited and intrigued by this and are starting to get engaged. Among other things, we plan to conduct formal training in the approach for about 600 people -- roughly 10% of our staff -- to create a core group from whom the process will spread.

Because this is a really new approach to things for an academic medical center of our size, one of my goals is to make sure that people feel they can also participate in the actual design and implementation. For example, I'd like for the training and communication process to be modified from suggestions of people as it proceeds, so that we refine it and keep things clear and relevant as we implement the program.

In essence, I want to create the organizational equivalent of a wiki -- a process that is organic during its implementation as a result of multiple and transparent contributions by the participants themselves. Think about that as allowing the people in the hospital to enhance the process improvement process itself even as that process is being rolled out. Think about it further as an incredibly and intentionally democratic design approach that puts great faith in the staff to know what will be most effective in teaching themselves about the program, for the benefit of one another. Now, add on to that characterization the fact that this needs to occur in a real-time manner and in multiple languages (English, Spanish, Creole, and others) and across multiple job categories so that all people feel confident that their points of view are heard and respected in a culturally sensitive manner.

We have some ways we are employing to do this, but I would love to hear from others -- whether in the medical field or elsewhere -- who might have tried this and can provide stories or references to their work. Please don't focus solely on computer information systems: Remember that lots of our people do not regularly look at a computer.


jessica lipnack said...

Paul, your request for advice reminded me of ""The Networked Community" project we did 10 years ago with Shell, published with the company's permission in Virtual Teams.

The project was a strategic initiative endorsed and actively engaged in by everyone from the top (CEO and senior leadership team) to the bottom (boiler maker and administrative assistants) - and, remarkably, by the community at large (spouses, clergy, school teachers and the like).

Interestingly, this was all before the web had really caught on and while we had email at our disposal, we had to rely on kludge-y knowledge management systems for document control. Frankly, the IT, while helpful to those who knew how to use it, was not that critical to the project's success.

Seven "enabling" recommendations resulted from the "Networked Community Fieldbook," the book collectively written by the core group, all of which have been implemented across the Shell group over time. And, on a personal note, the ties that came from being part of the project's effort have remained strong. Many involved say it was the best project they've ever participated in.

Perhaps you and your designers can glean a few ideas from how it unfolded.

e-Patient Dave said...

I have no experience yet with wikis, but when the time comes for a patient (e-patient!) component in your initiative you know whom to invite. :) (Monique, for one.)

btw, you might look into old HBR articles about the experience of organizations ~20 years ago with Lotus Notes. (I never used it - just offering my 2c.)

Anonymous said...

Speaking of "process improvement", you could do worse than start with the people who answer the phones and schedule appointments. They're not rude or anything, but you couldn't possible be any more unhelpful or bored.

Try this: call 617-667-2515 and schedule an appointment for "prostate ultrasound". Oh, and pretend (or don't pretend) to have never had one before, know nothing about what is expected, what procedures you have to follow, what preparation you have to make, or anything else about the procedure. And you're not even *really* sure where the building is.

See what happens. Go ahead. Try it.

Such was my Wednesday.

Anonymous said...

I applaud your initiative. I work at another healthcare organizatin that could only hope to have the human capital that your organization does.

I worked with a "bleeding edge" software vendor back in the late 90's until first qtr 2001 and Caregroup and BIDMC were at the forefront of healthcare.

Despite financial setbacks, it is apparent the BIDMC has not only recovered but is well on its way to leading the region and nation in healthcare delivery management and innovation.

Keep on Truckin'

Anonymous said...

In the nuclear power field, I was part of an internal employee team that was able to customize a commercially-developed web-based program that allowed anyone in the organization to submit a comment on any problem or even unexpected condition (no matter how small - e.g., the lightbulb is out in Room X). We had regular open meetings with minutes so anyone could participate. I would recommend that you adopt a similar course to develop ownership in the system. Internal teams should continue to meet regularly after first deployment to customize and make changes in accordance with feedback received.

Anonymous said...

My perspective is mainly on how not to do it, having experienced many such initiatives which started out with a bang but never really reached fruition. (I am not from Boston.)
One, you're only going to be as good as your 600 core trainees. Whichever ones of those (and there will be some) who are not so skilled or enthusiastic or committed will be the weak links in the chain. I assume these "trainers" are at the management level, so if the weak links are in charge of, say, the appointment schedules in Ultrasound (see anon 10:25), then you are at risk of that whole department not participating fully. I would feel better if you had some way of teaching at least the basics to everyone - perhaps a video that front line staff could view on their breaks in the employee lounges, or a program on your in-house TV system, or something? And you will need some kind of monitoring system, perhaps by your VP's, to detect very early which departments are not staying at the forefront.

Second, your "wiki" idea is a great concept if, as you say, it could be done offline. Perhaps old fashioned suggestion boxes or something similar? Then you have the problem of the suggestion readers throwing out ones they don't understand, or that reflect badly on their management, etc. You get the picture.

Then there's the whole matter of getting the medical staff, both attendings and residents, fully on board. I suggest you handle a lot of that yourself, as personal involvement of, and access to, the CEO means the most to those people (the attendings, anyhow).

What I am trying to say is that meaningful involvement of front line staff is both critically important to fundamental change, and simultaneously hard to achieve, if you funnel everything through traditional hierarchical channels.

Nothing I have said is probably new to you, but finding innovative ways to overcome these obstacles will be the key to your success.

david keefe said...

Engaging staff in the design and implementation of this training program will ensure its success. Based on my own training in Lean/Six Sigma at a Fortune 500 company and experience applying these to health care, I recommend:
1. Run a limited number (3-5) of focus groups comprised of 8-10 staff from diverse constituencies, identified by trusted managers as the most candid, communicative, staff who are "on the bus" with regard to the initiative.
2. Start each focus group with a charge, ideally from you, to identify what will and will not make the courses a success.
3. Professional group leaders summarize, affinitize and prioritize suggestions, and then help the group translate the ideas into a design for the course.
4. Write a standard operating procedure for the course, and pass it among key stakeholders and trusted leaders for input.
5. Pilot the training program on a limited number of staff, who also are "on the bus", and who are candid and communicative. Have this group evaluate the course on the critical to success criteria, and tweak it before rolling it out to the remainder of the staff, many of whom are averse to change, but bring other value to their jobs.
6. After each course survey trainees and trainers for what works and what needs improvement.
7. The training program itself should be interactive, focused, and fun. Plenty of (healthy) snacks should be available.
8. The training program should include a practicum, in which each trainee engages in an improvement project to ensure that the trainee goes through the course, rather than the course goes through the trainee.
9. Create a repository of projects, so staff seeking projects don't have to reinvent the wheel. Celebrate with a graduation ceremony, when trainees present their projects, and receive thanks and certificates.
10. Recognize the best projects with prizes and incentive pay.
11. Integrate the initiative into the DNA of the organization, by constantly driving home its importance, bonusing winners, and requiring completion of the training program for all promotions within BIDMC.
This approach has been deployed successfully in hundreds of organizations, but will not catch on in health care until visionary leaders like you gain support from their boards, and breakthrough the cultural barriers holding us back.

Anonymous said...

Paul, as an employee of BIDMC I applaud you for giving us the opportunity to participate in such a ground breaking project. I plan to give 100% of my support as an employee and will also encourage other employee of the importantance of this project.

Katja Hilska said...

We are using wiki as the organisation's intranet in the National Public Health Institute of Finland. It's been greatly adapted to the daily work and some (research) groups are using it very actively, others not so actively. The intranet with wiki-technology and wiki-way-of-work is new (only one year old) and I guess it takes some time to change the culture of communication and information sharing. The groups who are using it actively see the advantages of wiki and people say it has enhanced their work.

What was/is done in the implementation process: initial survey, wiki workshops, rounds in different units listening their neds, user education, another survey, interviews... It's much quicker to implement a new system than a new culture :)

I just want to say that it sounds like a great initiative, all the best to the project!