Tuesday, May 06, 2008

Midcourse lessons from SPIRIT

Here are some comments made after today's BIDMC SPIRIT training session (see some of the participants above). We are now winding down on training the first 600 people. As you can see, people quickly get to the core issues, problems, and opportunities. This is about where we expected to be at this point in the process. After all, we are introducing new concepts of empowerment, problem identification, and problem solving -- and sometimes people are confused or nervous. The suggestions from these trainees are exceedingly helpful. But look, too, at the last comment: Key messages are starting to come through. Then, see a bit of my analysis after the comments.

We noticed when logging our issue that you see “SPIRIT problems.” We think it would be better to look at “SPIRIT opportunities.” One idea we had was to change the language.

On the issue of what are appropriate call outs, several of us were talking earlier today that there seems to be some confusion out there about what it’s OK to call out and who can do it. At the beginning, it seemed that it could be about anything and everything and the staff would be empowered … then there seemed to be a reassessment and it became in some areas there are some things you can call out and some you can’t … that you have to go through the manager and the body language suggests whether this is going to go forward or not … and I think there are varied answers to these things depending on who’s speaking from the help chain.

How to fix this? I think just a reaffirmation of the goals and key principles to the entire leadership team, so that it is not interpreted in various ways by various leaders. In some places, staff aren’t allowed to touch the log without talking to the manager. We know we are trying to find our way and it’s early.

Talking about the “chain of command” has a connotation of fear in some places. Where we were, these were perhaps more junior nurses than in the PACU and they didn’t want to identify anything as a problem … it seemed they were fearful. For us, residents, it can be hard to call something out. We need an environment where all are equal and our insights are encouraged.

We’ve trained all the managers and supervisors and not the front line in this way because that would be overwhelming but perhaps we could do an in-service DVD that just lays out the key principles that this is all about. Staff are reading about this on the web, they are hearing things second hand, but if you (Paul Levy) could deliver the message it might help with the consistency of the message as well.

A big thing is … just because it happens all the time doesn’t mean it should. We see all of these problems. 10 minutes here. 20 minutes here. People think they are little. But they add up quickly. For those of us who are out there, they add up quickly to patients’ lives. 1 life. 2 lives. They may seem small but they aren’t. They matter. People need to understand that.

We started our journey toward eliminating hunting and fetching for every BIDMC staff member 8 weeks ago. We are consciously following the path trod by other large organizations in other fields (Toyota, Alcoa, US Navy submarine corps) that seem to do what their peers do to far superior results, in terms of staff satisfaction, quality, and business performance. The core of our approach is empowering everyone at BIDMC to call out when they hit a glitch in their work (see the problem) and participate in understanding the problem and developing solutions. We are learning how to provide the right level of help to them right away (swarm the problem), then how to share improvement stories transparently throughout the hospital.

Overall, we stand about where I expected, but some of the particular challenges we have are interesting.

We have plenty of evidence that it is right to involve each employee more deeply in problem solving, every day. Story after story has surfaced about how the people who do the work have pointed to the solution that could work – and is more likely to endure. Just last week, the housekeepers and unit staff in an ICU developed a solution to a chronic shortage of pillows needed to prop up their patients that has been driving them crazy for years.

We also are seeing the value of immediately investigating specific instances of problems, while the details are fresh. Using the observed details of what just actually happened keep us on the right track in a way that far-off committee meetings of folks who may not actually do the tasks being discussed may not.

And while we are still in the infancy of learning how to share effectively, people are picking up not only specific solutions from the SPIRIT log, but also insights on how to solve problems.

And people are paying attention. The SPIRIT log is often viewed more than 1,000 times a day, and my reports from SPIRIT here on this blog are being tracked by people around the world eager to learn with us.

So that is good, but we are still far from where we want to be in the breadth and quality of problem solving that will really make life as good as it could be for our staff. That’s what we expected at this stage of things, but it underlines how much work we have to do. What are the challenges on which we should focus at this starting stage?

First, the quantity of hunting and fetching investigation and solution attempts we are seeing is not even a small fraction of the challenges we know staff face on a daily basis. This is not a numbers game, but we do want to see much more high quality problem solving occur. Every person at BIDMC has something to offer (and gain) to understand this dynamic in their own areas, but here are some of the forces at work.

(1) It’s clear that in many places, it doesn’t feel “safe” for staff and managers to have problems in our areas being called and worked in the transparent light of SPIRIT. This sense is critical to overcome. When people feel more comfortable to bring opportunities to the surface and work them in plain sight, we will make the most rapid progress. It is the areas where I am not seeing any SPIRIT call outs that I worry about the most at this point.

(2) Some of us are so used to working around problems that we don’t even recognize that there is an opportunity to make the work easier. Some managers are countering this by actually walking next to staff as they do their work and helping them see what may be a “work around” and where there is opportunity. That works and can be helpful in these initial stages.

(3) Many people don’t really believe their boss wants to hear about their next hunting and fetching episode “in real time.” People have been implicitly rewarded in the past for solving impediments by brute force, and they think their leaders may not welcome reports of a “small” problem. After all, the managers are busy, too. We need to reaffirm that the responsibility rests with supervisors to actively encourage those who look to them for leadership to begin calling out opportunities to them in person. Of course, we won’t be able to work on every problem in real time until we get a lot better and faster at this, but we need to start.

(4) Some people don’t yet know how to “call out” in the most productive way. We need specific reports of specific problems, without blame. We need people to stick to the facts. And we need reports made in person to the immediate supervisor, not entered directly on the log unless no one is available to help.

Second, I see lots of opportunity to deepen our solutions, so that we are not only solving the immediate problem, but also applying the lessons to similar situations. For example, if CT radiology residents didn’t have an easy way to realize they were sometimes presenting their technologists with protocols that conflicted with the original physician orders (a “connection” problem), how many similar situations exist across our clinical services? We plan to begin pushing on these issues as we progress.

Third, though we are pleased with the orientation and training we have provided to almost 600 managers, staff have told us that they need more direct exposure to the SPIRIT principles and tools. We will expand efforts in this area shortly.


Anonymous said...

A number of the systemic obstacles identified by SPIRIT reflects the isolation of mid-level leaders, i.e. managers. Moving from a vertical to horizontal system is easier when work environments are already inhabited by peers. But most managers work in isolation from each other, and are given little time to develop skills within a peer group. This fosters hierarchical thinking and control issues. And in fact, most are hired because they demonstrate skill in these areas.

To create an openness to managerial problem-solving, managers should have more opportunities to exercise peer-level interactions. They should develop colleagues across departments and be rewarded for the number of call outs and diversity of employees that are heard from. They need peer models, and they need to see themselves as leaders rather than only managers. Show them the carrot!

Anonymous said...

I second anon 1:05's comments. Relative to his/her point, I copied one of Mr. Spear's statements in an interview ("How Toyota turns its workers into problem solvers") that you, Paul, referenced in one of your original Spirit posts:

"We found that in the best TPS-managed plants, there was a pathway of learning and teaching that cascaded from the most senior levels to the most junior. In effect, the needs of people directly touching the work determined the assistance, problem solving, and training activities of those more senior. This is a sharp contrast, in fact a near inversion, in terms of who works for whom when compared with the more traditional, centralized command and control system characterized by a downward diffusion of work orders and an upward reporting of work status."

My comment relates to this relationship between the managers and front line workers. If the front line people are not specifically trained in Spirit and are required to call out the problem to their immediate supervisor(rather than putting it in the log), then who is monitoring whether the supervisor is responding according to the principles of the quote? The staff's perceived lack of "safety" in call-outs may relate to weaknesses in this area.

I reiterate my statement back last January 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.

Specifically, I agree with your respondent who suggests an inservice DVD for front line staff delivered by the CEO himself - sending a message to both the front line staff and to those few managers who may still be trying to make themselves look good rather than solve problems. (Besides, I've seen you on camera and you look good there! (:)

Having said that, the numerous examples you have provided in previous posts are good evidence of encouraging progress. Keep up the good work!

nonlocal MD

Anonymous said...

When a staff member works only nights, 12 hr shifts, from 7pm-7am, nearly 40% on weekends and/or holidays, managers are an unknown unless that staff member is in trouble! In the many years that I have worked here as an RN, I have never seen a staff meeting, or any other meeting that was scheduled off shift. There are many people who work only nights, and we are left out of most everything. To have to refer a problem to a manager instead of dealing w/ it in real time is a joke.

Anonymous said...

Hmm, there is always some senior person on duty . . . but your points are well taken.

Anonymous said...

There is a manager on site during weekends and the off-shift, the Administrative Clinical Supervisor. All the ACSs have been to SPIRIT training and are prepared to receive and work on real-time call outs. They will work on the problem as far as they can and will activate the help chain if they can't solve it to root. Please do call these folks when you encounter a problem.

Marsha Maurer, VP for Patient Care Services and Chief Nurse

Jay Levitt said...

(Side question: How is it that average folks are able to find you to send e-mail? I thought I was pretty smart, but I can't find any contact information on this blog or the BIDMC web site. I think a "write to the top" feature might prove interesting.)

I've been fascinated by your application of real-world management principles to BIDMC; it's exciting stuff, whether it succeeds at first try, or serves as a platform for learning how hospitals differ from corporations.

My reactions after reading this note:

* Names aren't everything. But "SPIRIT" is, well, hokey. Most acronyms are. Who has spirit? Cheerleaders. Summer campers. "We've got spirit! Yes we do!" The can-do name may appeal to you, but I suspect it's a subconscious turnoff for exhausted, frustrated health-care workers; it's an invitation to be cynical. You might as well call the program "kick me".

* Exhorting doesn't work; rewarding does. Think behaviorally, not cognitively. What does everyone want at work? Less work.

Call it "Be Lazy". "Are you running into the same obstacles at work every single day? Be Lazy. Tell us what would make your life simpler. What's the one change that would make your daily grind smoother?"

You're trying to get people to "call out". Nobody wants to call out; the very name is reminiscent of tattling, or complaining, or, at least, making an extra effort. That's not appealing. But laziness is - and it's fun. People would chuckle as they submitted suggestions to their boss. And they'd have a great excuse: "Hey, look. I'm just being lazy, like you said."

You can't create new instincts by memos and fiat; you can only appeal to our innate ones.

* #4, in-person reports: Same problem. People are not comfortable speaking up in the moment. It's much safer, emotionally, to just write it down for someone faceless to deal with. This is why we often try, inappropriately, to deal with conflicts via e-mail.

You can try to fight that instinct with memos, or you can leverage it to get better feedback.

Anonymous said...

The senior person is usually not on site at night, in most of the hospitals I've ever seen.

Anonymous said...

Jay, thanks for all your thoughts. (1) The name SPIRIT was chosen by our employees in a vibrant election campaign with over 2000 votes cast! (2) Most everything we are doing with SPIRIT is in person, not by memo, but the occasional memo from me can be a helpful touchstone to some staff,too.

Marie said...

Paul, I'm one of the many tracking progress on SPIRIT "eager to learn". I'd like to understand the call out process.
1. I didn't realize until this post that staff don't log directly, but speak to their supervisor who then logs the call out. I would be concerned about what information is lost. Not only is access to supervisor a factor (the Chief Nurse saying you have access but the employee saying they don't is a big disconnect you'll want to close), but the description of the issue shifts to someone else's perspective and bias. Can a staff member review entries? Could it be both say and log?
2. Barriers to safety and quality include staff and management behaviors. Is it safe to call those out? What are your guidelines?
3. You could be receiving thousands of call outs. How are you handling volume? Did you start by asking for only those having to do with "fetch and find" as a way to manage volume?
4. I admire the commitment to training all management first. How did the remaining employees learn about the call out process? The post seems to indicate that many don't have information. Perhaps you are phasing SPIRIT in by department and training as you go?
5. The call out log would be a rich source of data. How is that being analyzed? Reported? Are you using Access, Excel, Sharepoint?

Thank you so much for sharing your learnings as you go!

Anonymous said...


1. We are encouraging that staff talk with their managers/supervisors to "call out" the problem and to activate problem solving. Either the manager or the staff can then go ahead and post the call out on the log. There are many call - outs that are still occurring to the log, without any communication to the supervisor/manager. We are very early in our process of rolling this out, so we are watching and learning from these call-outs as well. Many of them cannot be solved because they are just too non-specific. Part of our ongoing education is that the log is just that... a log... it is not really intended to be a notification system.

The log is visible to any and all staff on our intranet portal. The "solving to root" process and the work toward the solution are chronicled on the log for all to see.

2. Great concern about the behaviors. We do have call outs about behaviors, several of which have been disconcerting. Most of these are anonymous posts. We continue to discourage anonymous posts - this is one of the patterns that we are closely observing to see what the postings tell us about organizational safety and our culture.....I am sure that there will be much more to follow as we get more experience!

3. We are actually NOT receiving nearly as many call outs as we anticipated. We are working to INCREASE our call outs with our ongoing educational efforts and our communications to our leaders and staff about the program. Our observations of work during the orientation sessions clearly demonstrate that there are infinitely more hunting and fetching activities then we even are aware of in our day to day work as they have become so much a part of our routine!

4. The leadership team is still being oriented, so it is not surprising that staff may not yet know about it. Those through the orientation process are working to carry the message forward and to demonstrate real time problem solving with their staff, but we know that this is going to take a lot of time!

5. We are just beginning to evaluate the emerging themes and determining the appropriate measures to really capture this. There are probably facets of organizational culture of safety, patient and staff satisfaction that could all be influenced over time - but time will tell. We have also done some pre implementation observations of work to get some measurements of how our staff spend their time.

Thanks for these great questions!! I will keep you posted.

Anonymous said...

In response to Marsha Maurer's entreaty that staff seak out the ACS during the off shifts, I would ask how 1 person (sometimes actually 1 on each campus) can effectively take the place of dozens of managers and resources, and provide an equitable response to all the needs that this facility would face at night. We are a REAL hospital at night and though it might come as a shock to many, patients do not sleep at night, problems are harder to solve, and most ancillary departments are closed. This includes any way to get food to staff, patients and visitors after 11pm, provide Social Services after 9pm (people better not have crises at night), or provide many other services that are available during "normal working hours". Most of this effort at problem solving has been profoundly lacking in every way towards more than 50% of the Hospital's staff and events..."off shift". Even this reference connotes where the facility, and the culture, stands about the needs of the "graveyard".

Anonymous said...

Dear Anonymous, The ACS is actually well positioned to support the SPIRIT program. They are already routinely called when a staff member has a problem. Developing their ability to think about the root cause of that problem, in addition to resolving the immediate issue, will be helpful in developing solutions to many chronic problems.

With respect to the specific off-shift problems you raised in your post, I know that the issue of availability of food on the off-shift has been called out and is being worked on. I don't know that there has been a specific call-out about Social Service coverage, but I would encourage you to do so when you next encounter that circumstance so we can understand exactly what resource is needed.

While not exactly the same as Social Service coverage, but related to crises on the off-shift, I know that Reverend Julia Dunbar, our new Director for Pastoral Care, has identified the availability of chaplaincy services on the off-shift as a problem. In addition to providing off-shift chaplaincy services herself, she has developed a robust call schedule to ensure there is always a chaplain available when needed.

Jay Levitt said...

Wow... fascinating to see process improvement totter in real-time on the web.

@Paul: Thanks for responding.

"The name SPIRIT was chosen by our employees in a vibrant election campaign..."

My point exactly. Creativity (or skill, for that matter) doesn't stem from democracy. Wanna have a vibrant election about the hospital name? Your salary? Prophylactic use of antibiotics? Of course not.

As for the "memo", I wasn't talking about the choice of written vs. oral communications. What I'm saying is that you can't change human nature with a procedure manual. I know; I've tried too.

You're pitting a set of guidelines against a few million years of evolution. Guess which wins? If you simply reiterate and re-emphasize those guidelines, you're doing this:

Tourist: "Excuse me, which way to Valencia?"
Local: "Que?"
Tourist: "I said, WHICH.. WAY.. TO.. VALENCIA?"

The exchange between Marsha and anonymous is a prime example. If your employees tell you that something doesn't work, then it. doesn't. work. Responding with an explanation of how it should work, or how it often seems to work, misses the point entirely. It reminds me of the architect who, when I said I wasn't satisfied, told me, "I don't think that's true at all." Oops, my mistake!

You're making a classic business blunder: The best product feedback you have is what people do with it. Don't try to convince them to use SPIRIT the way you imagined; watch what they actually do. When Adobe first started, they thought they were selling computers and printers - and nobody wanted them. Xerox said "We already have printers. Can't we just buy the software?" No. Canon: Ditto. Finally, when Apple came along, they realized: They are telling us how they want to use it. Let's listen. (Go read "Founders at Work" to see this same story happen at 40 different companies.)

Every time an employee logs something without talking to their manager, they are saying, very clearly: "I want to be able to call out without a face-to-face conversation." That IS a call-out, in itself. And, according to your own reports, and blog comments, it's happening over and over. You're just not listening to it.

Stop trying so hard to get your staff to adhere to the system; start trying to make the system do what they're implicitly asking for. That's much easier.

Anonymous said...


It is early yet, and people at all levels are feeling their way. What you don't see are many changes we have made in response to suggestions.

The trick here is to balance our desire to create what I call below the organizational equivalent of a wiki (and that is also what you describe) with the need for many people to feel a bit more structure. That is a normal push-and-pull, especially in a place with over 6000 people. Stay tuned.

Anonymous said...

Well, not to join the discussion needlessly, but to an outsider there does seem to be evidence that things function differently at night than during the day - just like any other hospital in the U.S. However, that doesn't make it right, nor further your goal of eliminating preventable harm by 2012, or whichever year you picked. And there is good medical evidence that events which occur in hospitals at night or on the weekends are more likely to have a bad outcome. (I can provide a reference if asked; I believe it's in the NEJM recently).

Because of this evidence, I have to agree somewhat with Jay that instead of arguing that your current ACS system does work, you should actually look into it.

I would bet dollars to doughnuts that most, if not all, of the ACS's, when presented with a nonemergency callout on the night/weekend shifts, try to defer it to the regular workweek/day shift rather than solving it in realtime. I would suggest Ms. Maurer look into this and see for herself, rather than assuming the system works as she describes. My specific suggestion would be for her to appear unannounced on the night shifts periodically and see what's happening, rather than listen to what the ACS's tell her.
The old "management by walking around" yields surprising information - and also sends a message that administration really does care about the night shift.

Marie said...

Please extend my thanks to Pat Folcarelli for the thoughtful response to my questions on the call out process. Your team commitment to this form of open space learning is remarkable. I look forward to future updates.