Reflections on improvement overburden

Quite recently I have gone back ‘into improvement practice’ after doing my PhD and policy jobs for the last 5 years. So back into the cut and thrust of ‘doing’ improvement work rather than thinking and writing about it. Back to many, many different (and often conflicting) improvement calls to action, so often well reported now by NHS Providers and others. National initiatives, national regulatory must do’s, regional initiatives, regional must do’s, new benchmarking and audit reports, organisational and local initiatives and must do’s, fabulous ideas from staff and patients, endless ideas from those outside wanting to help, including academics, suppliers and management consultancies. A never-ending stream of ideas on what needs to be done to improve care, so many in fact, that the how, can become confusing and overwhelming, even taking the first step forwards can seem paralysing and impossible. Just another thing to do.

Coming back into practice from the ‘centre’, I reflect that it is too easy to forget just how much pressure teams (staff and line) are under. The (often nursing focussed) research about work left undone due to simple time pressures seems so utterly true across all different work groups. In fact it is almost a wonder that any improvement work happens at all, with the seemingly ever growing demands from all angles. Never mind the additional work needed to try to fit all these different needs, asks, ideas and wants together into some kind of priority order, logic, narrative or sense, and clarity of how to proceed.

Yet at the same time, whilst there seems too much to be done, it is easy to spot waste, errors, harm and defects, and recognise the good intent and value behind so many of the asks. The very things that, if we could just find 20-30 mins for improvement work a day, we might be able to work out the how and do something about them. The work left undone such as when the photocopier stops working actually calling for the technician rather than leaving it jammed for the next person to find. Work left undone like actually adding and tagging something properly on a shared workspace, instead of filling other people’s inboxes including my own, so I and others can’t find things later, or worse there becomes several uncontrolled copies. Work left undone such as not filling in data collection sheets fully, so ad-hoc systems need to continue for longer for all as ‘not enough data’ was collected. Work left undone such as forgetting to open my outlook calendar so others can see it making meetings easier, timelier and quicker to arrange. Or staff just staying that two minutes longer with a patient answering their questions that might make their confidence and happiness to go home just that bit higher. Work left undone, such as a hospital letting a family know their grandad had been discharged so they could help him get settled back in at home, instead of having to be readmitted only hours later having not been able to get himself a drink or put the heating on.

Little things (and some big ones) you say, true, with a big impact on both time, and everyday irritation, frustration, obstacles, and always waste and potential harm. That adds up. It is precisely those kind of so called ‘little things’, that have inspired the great work by Daniel and Rachel in Bradford with their improvement movement 15s/30m to get more joy in work, by helping you do more of what you came to work to do. To meet your goals, be they personal, professional or organisational.

This idea of overcoming obstacles today, to help you and your colleagues meet your goals tomorrow, is particularly resonating. Over the last couple of months I have been learning much more about the Toyota Kata approach*, in many ways the invisible part of lean and for the last 25 years, perhaps the ‘missing link’ left out of Western attempts to copy and implement lean and/ the Toyota production system.

The Toyota Kata is an approach to every day improvement and coaching routines to support learning (Rother, 2017; 2018). It is also an approach designed to take a small amount of time each day, say 20 minutes, designed for learning that may lead to a bigger impact, one obstacle at a time. In a nutshell, it supports thinking scientifically about improvement by asking ‘if this is your bigger challenge… then what is your goal (target condition) over the next 2-3 weeks, and what is the first step to tackle one of the obstacles that you need to tackle, to achieve that 2-3 week goal (target condition)’. Breaking a challenge into the how of the first step of ‘what needs to be done’ seems much smaller, easier and less time consuming, somehow just makes it seem that much more achievable, that much more accessible and that much more motivational to me. I suspect that might well be the case for many others too.

Yet, as I write this, I think of how such ‘small’ steps might fit into an NHS (English) context, described somewhat cuttingly, as having a risk of gearing itself up to be a plan publishing house, for when the next NHS Plan is published this winter. More ideas, more initiatives, more what… perhaps even less how. How would kata ‘next steps’ have legitimacy across the health and care system, within those kinds of conditions? Where it isn’t certain what the second step will be, never mind the tenth one, as each step depends on what is learnt during the previous step. How would a Kata approach fit into a system, where grand and lofty policies, plans and ambitions of integrated care, better care outcomes, budget pressures and new targets fill the strategic narratives, think tank agendas and dialogues? Yet, Kata (at scale) might just offer this approach, by linking obstacle removing steps to grand challenges. This is it is reported, by Mike Rother and colleagues, is how Toyota has moved its improvement work from shop floor technical engineering of production lines to a mainstay of rapid strategy execution. Learning at scale, everyday, how to deliver value through ambitious challenges.

This seems to be done with little overburden for staff (notwithstanding the general critique of Japanese overwork culture) due to the self discipline of the leadership (global and factory) on global and corporate goals and programmes. Kata practices seem to be linked to corporate goals and global ambition through the lean approach of policy deployment (hoshin kanri). Limiting programme and initiative growth at the top, so that they don’t proliferate and become stagnant through overburden elsewhere.

As I learn more, developing Kata practices alongside the use of an system-wide / organisational and systematic approach to improvement (such as lean), seems to me at least, one of the ways for organisations to gradually move away from the ambidextrous narrative that suggests we all have two jobs. That metaphor in itself, to me, sounds like more overburden, even though I am confident that is not the intent behind the statement. Moving away from that metaphor might help us reframe improvement practice inadvertently from overburden, as another second thing we all need to do, but instead just how we do our job. By making improvement practice, coaching routines and leadership behaviours for learning ‘become so normal’, that the very idea of two jobs seems almost nonsensical because learning and adapting everyday is part of everyone’s job. The culture has been modified so much, through the use of Kata, that learning is inherently part of the culture, learning and improvement routines are just how we do things everyday, by everyone.

Want to banish improvement overburden? We can all be 15s30m movement makers here… all of us can think about what asks and improvement ideas we might remove or combine, saving a little up front and thereby reducing the overburden and work left undone later. Then we have more time to focus on the ‘how‘, to tackle obstacles that are currently preventing us from achieving our challenges, systematically, one by one. What’s our next step to to meet that grand challenge?’

* Thanks to the many people supporting me in being a kata learner these past couple of months. Very much appreciated.

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Matching Michigan: what can we learn from Zingermans and Mercy Health?

Last week my colleague Ann and I, were lucky enough to visit the University of Michigan in Ann Arbor to learn more from Drew Lochler and colleagues about the much lauded ‘Toyota Kata’, first described in the book of the same name by Mike Rother back in 2009. This included two site visits to Zingermans mail order and Mercy Health in Muskegon, on Lake Michigan.

I was a little curious and hugely, ‘Kata’ means routine, rather like practice routines such as learning scales on an instrument. The idea of spending a week examining improvement routines with some the best minds in the business was enticing, especially given the focus of my PhD on routines and capability. (I confess to also being a little sceptical, is kata yet just another improvement ‘brand’ or ‘fad’, repackaging the old, confusing the masses and generating a new round of books and conferences e.g. Katacon?). After a whirlwind trip to ride in a Model T Ford at the birthplace of mass production in River Rouge, and arguably lean after Toyoda’s visit there to see the moving production line, we arrived bright and breezy at the Barn of the Year 2015 (who knew you could win that?) to start the programme.

At first the kata seem remarkably simple (see above), I mean don’t these questions seem kinda obvious? Drew explained to us how the questions have much in common with A3 thinking and are used in Toyota alongside the more commonly adopted tools and processes such as kanban, 1 piece flow and jidoka. But, he explained, kata is the missing link in most improvement efforts who adopt the improvement tools, the purpose pyramids, the value stream analysis, the collaborative etc., yet fail to mimic the improvement and coaching practices to develop people alongside the tools, as these have often been unnoticed elements of Toyota culture. And that these kata (routines / practices) are critical to success, sustainability and ongoing continuous incremental improvement. Further he argued kata helps to counter the problems created through narrow and deep focussed value stream analysis and rapid improvement event lean deployments that can only ever touch a small number of staff quickly. Teach a man to fish…

So over the first 2 days with the help of a 15 piece child’s jigsaw, a small lanyard with the questions on and a tub of sticklebricks we set out to learn some new improvement routines and habits, our starter kata. We were also lucky enough to have a slightly starstuck lunch with Mike Rother to talk Kata in healthcare. It is fair to say, the kata questions are deceptively simple, the art of these questions come both in the ability to agree stretching yet achievable goals and the more specific the better. ‘The best goal (target condition) is one that will make you wanna hurl‘ the wonderful Betty from Zingermans told us.

Kata is set up for a learner, a coach and a second coach, typically through a line management chain rather than improvement experts. The process also requires a fair amount of trust and respect for people in line with one of the founding principles of the Toyota Way. Embedded in the kata questions is coaching and rapid PDSA aligning with organisational/system goals or True Norths. The questions are designed to help learners to the edge of their threshold of knowledge and just move them to out of their comfort zone whilst being explicit of the purpose and the theory of change. ‘How will you know?’, being a repeated follow up coaching question, the harder part for coaches being to stay quiet and not suggest (or worse) impose solutions.

In the second two days, we saw kata being used to solve challenges alongside more established lean practices at Zingermans mail order, and Mercy Health. At Zingermans, most redesign work and implementation of takt, flow cells, visual management etc, had been implemented and kata was being used by staff at key problem areas, revealed by these improvement tools, to ready for peak demand at Christmas, regularly. At Mercy Health, the mission control / big room (Obeya room) was set up to use the kata during the exec meetings and an open kata challenge was being used to improve the meeting itself. In that meeting the CEO acted as the learner, of her by a member of the improvement team, in front of his senior leadership team. Talk about CEO role modelling.

We were lucky enough to observe several open kata challenges in ‘lanes’ at Mercy ranging from infection control, LoS reduction and car parking. And Maurene and colleagues at Mercy ensured we got some more practice in encouraging us to be a coach on 2 occasions. In all cases the strength of making the kata explicit and part of the improvement process was tangible and emotional. We observed staff share their challenge, data (often local and manually collected) and saw PDSA frustration, success and explicitly their learning whilst verbally contacting with their coach their next step to be reviewed often in the next couple of days. I’d like to blame it on the jet lag, but Ann and I often felt moved to tears with the pride in the work, and the clear, and measurable, patient benefit.

For me, I was particularly interested in how to bring together traditional ‘event’ based lean deployment with the kata routines. Mercy had done this in two main ways. 1) through concurrent implementation to spread in areas without large event based improvement work, instead building on the enthusiasm and existing improvement work in the teams and 2) incorporating kata into improvement events in-week as rapid experiments and then throughout the 30-60-90 follow up process, largely eliminating the need for post-hoc facilitator reviews.

Indeed their ‘meta-kata’ work on improvement practices and routines demonstrated the benefits of this approach through improved sustainability and reduced facilitator time needed, especially for data collection. In fact, Mercy are now spreading kata and see reduced need for improvement events as the practice of regular and locally coached improvement practice (kata) spreads. That is not to say that improvement events are not without value, they too provide a whole system and team base perspective and are arguably quicker, ensuring change and important learning for kata to build on whilst the slower to master kata coaching and improvement routines develop. ‘Go slow, to go fast; develop your people, to develop your processes‘.

Is kata a fad? I didn’t get that impression. Does kata seem worth it? In Michigan, it certainly appeared so.

So what does that mean for me? How can we match Michigan in their use of kata? What did I learn? 3 main things: 1) I will have to unlearn some improvement habits whilst I learn new kata habits, (probably painfully). 2) Improvement events, workshops, collaboratives etc. have their place, yet kata is arguably more able to take context into account and is more engaging, accessible, successful and sustainable. And 3) many of our assumptions of what staff need to know about improvement as part of induction and beginner programmes e.g. run charts, 5S, driver diagrams, etc., may possibly be completely flawed. These 3 areas will undoubtedly also be some of my obstacles going forwards.

What I noticed was that kata learners and coaches can use the starter kata almost immediately without any QI/Improvement training. Improvement expertise can be shared by coaches on a need to know basis when a learner is at their threshold of knowledge in a PDSA cycle rather than batched in a training programme (thus also making the arguments about which improvement method is best, utterly pointless, if they weren’t already). This for me is significant in healthcare, with the inexorable rise in QI/Improvement training, certification and academies, and associated costs and waste. Kata ensures skills and improvement capability, (as a bundle of routines), is developed through practice, within the local context. Just like with karate forms, mastering the routines is critical and people development the goal, wherever they start, rather than through training per se.

So, what’s my next step? I’m so excited, it is hard to think of only 1 out of all of the possibilities. But following the kata principle of 1 problem at a time, my next step is to: identify 1 learner and 1 coach to use this concurrently in my value stream analysis next week in Lancashire (coach, is that specific enough?). What do I expect? That it demonstrates a new way to enact improvement actions as part of the event and the two participants will also find it useful (I hope).

Finally, as Zingermans would say, appreciation: thank you sooooooo much to all who shared time, learning and their coaching expertise with us on our trip, especially Drew, Sam, Toni, Mike, Betty, Maurene, and many more, and also to Dianne for sorting all the arrangements! Special thanks also to my mum and dad for looking after my kids for me during the school holidays, facilitating my travel.

Hope to keep learning with you all going forwards.

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Kanban: can we follow the learning from Pied Piper in ‘Silicon Valley’?

Youu may have seen the rather clever and funny HBO sitcom ‘Silicon Valley‘ exploring the lives of five white young male software engineers build a startup called ‘Pied Piper’. In the show, the team at ‘Pied Piper are developing their new IT products, and you may be familiar with the whiteboard often in use when they are in the midst of a massive amount of code programming. (This massive amount of code programming I believe is also sometimes known as a sprint, I think they are loosely modelling an agile improvement approach in the programme).

The whiteboard seems to represent a really simple process. At the fictional ‘Pied Piper’, this consists of three columns, one for ‘to do’; one for ‘work in progress’ and ‘completed’ (or similar wording). In each column is a number of post-it’s with a task on, all starting in the ‘to do’ column. A programmer picks one post–it from the ‘to do’ column, accepts it as his (and in this programme they are largely all male) and moves it across the board accordingly. This simple process allows everyone at a glance to know who is working on what, and how many tasks still need completing. The team of ‘Pied Piper’ plucky engineers love celebrating after their frequent all nighters when all of the post-its that detail each programming task have moved from the left hand ‘to do’ column to the ‘completed’ column.

Increasingly, I have noticed that this type of board is becoming ubiquitously followed and used in offices and other settings often referred to as a ‘kanban board’ or sometimes a ‘personal kanban board’ which increasingly has made me feel a little uncomfortable. Why uncomfortable? Because in these examples, kanban is being viewed as a simple visual management process for managing workload, and yet for me this doesn’t really resemble kanban at all, and only very partially meets the principles of kanban. In short, whilst these have undoubtedly good intent and are helpful, these types of whiteboards seem to be more workload tracking systems, than kanban systems. And I’m not even certain that a kanban boards is a good name for them. This is because for me, they lack fidelity to the practice of kanban and these boards could be more effective work organising systems through more careful application of kanban principles.

So, if we can’t follow ‘Pied Piper’ to learn about kanban what can we learn?

First, a kanban is a cardboard card, rather than a whiteboard. Each card corresponds to an amount of work/work task. So at ‘Pied Piper’ the kanban card is each separate post-it. So far so good you say? That still seems like kanban? Yet each post-it at ‘Pied Piper’ may not equate to the same amount of work… one might be a 30min task, another a 3 hour task. So how does the ‘Pied Piper’ system really help us to visualise workload?

Second, A kanban system is a card system that materialises information to ensure we can visualise flow, both material and information. Again… so far so good at ‘Pied Piper’, we can see tasks flowing across the board… but how much information can we see? Is it clear how the tasks connect?

Third, There are two main sorts of kanban cards (Balle et al, 2017):

1) withdrawal cards: these are mini ‘purchase orders’ for each task, tasks/information cannot flow to the next step without a withdrawal card to trigger the movement. This card represents demand.

2) production instruction cards: when a task is triggered by a withdrawal card, a related production card it is sent to trigger the start the the production or service task as a request to start, e.g to the programmer. This card represents the production response to the customer demand, is an extremely visual way, and helps to see blockages.

Can you see these two cards and their functions on the ‘Pied Piper’ whiteboard system? I can’t. I can only see one, which might be ok, if they have done something else in their system… but I can’t see it. I usually can’t see two systems one for demand and one for production in office systems either, yet work in offices is rarely ‘produce by only one person’ so surely some kind of ‘production order’ is still needed in response to the customer demand.

Kanban (in lean) is used as the basis of just-in-time and one piece flow, and was based on the idea of supermarkets where customers pick what they want and shelf stackers fill in the space on the shelf after they have picked their product. Kanban imposes discipline to ensure no more than needed is produced, in demand order according to the customer and kanban supports other processes linked to getting it right first time. (at ‘Pied Piper’ the programmers correct all their programming errors at the end, rather than as they go).

The purpose of kanban is to have the least possible number of cards possible in use at any one time. This minimises work in progress thus the cost of inventory and stock holding. For example, if an employee has a whole pile of task post-its, or a whiteboard has more post-its in the work in progress column than it has staff working, then this defeats the purpose of using kanban. The post-its (cards) are not being used to drive one piece/task/decision flow.

This is important because studies show that there is as much as 20% lost time as employees switch between different tasks without completing them and the risk of errors and mistakes increases. Kanban when used correctly enforces a limit to the number of tasks anyone person is doing at a point in time. This also has an added benefit for employees as it reduces overburden and the interpersonal conflicts and frustrations that can arise from resource allocation decisions.

Nevertheless kanban is also difficult to learn and use, I am still learning its intricacies, and how kanban principles can be applied in healthcare, and yet it is deceptively simple to look at and consequentially mis-understood and imho, mis-applied.

The book ‘The Lean Strategy’ (from which I have drawn heavily in this post) suggests that a way of managing office based workloads such as that in the ‘Silicon Valley’ programme might need 2 whiteboards (Balle et al., 2017, page 101). One containing ‘to do’ tasks without prioritisation, and another containing a grid sized for capacity, and new tasks can only start when an aisle is freed up (see photo below).

Photo from The Lean Strategy, Balle et al., 2017, page 101

This process controls the flow of work tasks, limiting batching and work in progress, and even more importantly, reveals where problems and overburden in workflow are. For service tasks such as programming, designing, policy making and product development, the daily practice of reviewing flow by all team members and leaders together to solve problems, reveals holds ups, errors, delays and where team members need help (do we see that at ‘Pied Piper’ or most office based systems?). It also illuminates where there are areas of over processing and overwork, leading to simpler and more elegant designs and can accelerate office-based productivity.

So whilst, I can see the attraction of simple whiteboards used to visualise workload tasks… for me at least, these are not really kanban boards, because these 3 column whiteboards fail to benefit from the potential of kanban by failing to apply the principles that underpin it. For me, the name of the board and the language used matters. Fidelity of use matters, because if other learn to use ‘kanban boards’ that do not hold true to the principles of kanban. And learners perceive them as ‘best practice’ or similar, then the benefit of such visual systems will not be felt and misunderstandings of what kanban is, and isn’t, and what it can be used for, may fail grow further. Possibly perpetuating messages of that ‘improvement’ stuff doesn’t work.

So I am not going follow ‘Pied Piper’ and use a similar whiteboard workload tracker from but I am going to keep learning to use improvement tools like kanban with as much fidelity as I can, to keep benefitting my customers, and in healthcare, our patients. If we are going to practice improvement, is it not important that we try to practice it well?

What’s your view, does fidelity matter? Am I being too technically picky? Does method really matter that much for this? Is this just a difference between agile and lean approaches to improvement? Do you disagree? Love to know!

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Surfing the waves

What a week! Seriously, I’m sitting in the garden reflecting not only on the unusually good weather, but the most amazing week of learning and connecting about improvement research and practice.

This time last week, I arrived in Montreal for the international conference in organisational behaviour in healthcare (OBHC), (thank you, as always, Health Foundation for funding my PhD and its dissemination). It’s a super conference covering many aspects of improvement, and strategic and organisational theory. The event started for me as last time by (losing my luggage and) meeting many early career researchers and PhDs. In what can only be described as a shouting frenzy, we enthusiastically participated in a round of speed networking, fantastically facilitated by Prof. Cathy Pope, where amongst other things we were asked to discuss our superpowers and our best teacher. The best part about this is that we all made many new friends, learnt about each other’s research and we were not at risk of being lonely at the conference.

After a hike up Mont Royal, the following day the conference opened with a plenary about crossing paradigmatic boundaries. This included reflecting on the current state of the field including the need for pragmatic and real world trials, and the need for much more ethnography to develop insights to explain and influence organisational behaviour in healthcare. After this was a torrent of breakout sessions, for me the strength of this conference, with such a diversity of topics. I heard sessions about organisational change capability in Wales, knowledge mobilisation using boundary objects (I didn’t know what they were to begin with), leadership for quality improvement development programmes, the negative impact of leadership churn on quality improvement, the role of middle management in improvement, improvement sustainability, second victims in patient safety and so on. I was also delighted to present my theorisation of improvement capability.

I especially loved hearing from A.Prof Liz Wiggins and colleagues about their work to understand and develop the leadership of improvement via the GenerationQ programme (I am a former participant). This work (in press) describes leading improvement as ‘surfing the waves’ between perspectives, relationships and world’s; taking a complexity perspective to influence learning and practice in healthcare, one conversation at a time through leadership gestures and responses.

Two main highlights were a keynote from Prof. Henry Mintzburg speaking on managing the myths of healthcare; and the work from Prof. Stephen Shortell at CLEAR and colleagues to evaluate lean programmes in North America. I find this work very exciting. First, was research to evaluate the audacious lean programme in Saskatchewan province in Canada followed by a national lean survey in the USA. Shortell et al’s survey and analysis begins to demonstrate much needed research evidence of the positive [self reported] impact of lean (and other robust improvement) programmes especially after they begin to mature (warning for those looking to lean for a fast fix, this study shows impact really only starting after about 8 years of implementation). Whereas, the Satskatchewan story is rather depressing to hear, but nevertheless, there is much learning from the programme for other national and large scale lean programmes, to learn from. Not least ensuring early engagement of physicians, not being too fast/aggressive, being careful with jargon, the need for continuity and commitments from leaders particularly CEOs and being thoughtful about the personal and political risk leaders take. Thinking about our research which demonstrates a tendency of national orgs to focus on the ‘doing’, i.e. improvement tools, governance and data, the Saskatchewan story perhaps also a re-emphasises a cautionary tale, that lean programmes, particularly large national ones, must listen to stakeholders and patients from the beginning and pay as much, if not more attention to culture and leadership, and the political risks of such an endeavour.

Which brings me neatly to the end of the week, where I crossed back over the Atlantic boundary and joined the NHS Improvement (where I work) lean conference, (as far as I know, this was the first ever NHS led national lean conference). It was brilliant to reconnect with so many friends and colleagues from lean work, from the Virginia Mason partnership with 5 trusts, the NHS Improvement seven trusts embarking on the Vital Signs lean programme, and colleagues from NETS, CLIC, and from the Bolton Improving Care System (BICS). I was so proud to be there and I loved it. It was exciting, inspiring, energetic, and connected to research and practice, and so in a way for me, it felt like home.

Dr John Toussaint, from Catalysis and former CEO of Thedacare, from where Bolton learnt so many lean lessons, opened with a keynote discussing his personal lean leadership journey and shared 5 leadership lessons from organisations that he and colleagues have worked with. His keynote echoed the research lessons about the significance of culture and leadership, especially that of the CEO, from earlier in the week at OBHC. ‘Surfing’ between research and practice, he also shared Shortell et al. work and commented on the implications for practitioners and healthcare policy makers.

So after ‘surfing’ between improvement theory and practice this week – between two different world’s, associated paradigms, with seemingly different aims and remits, different communities and identities and many epistemic boundaries, there seems much to share and learn from both.

It is reported in an article by Prof. Jeffrey Braithwaite, that: only 50-60% of healthcare meets level 1 guidelines; healthcare expenditure seems to be 30% wasted; and adverse events remain stubbornly at a rate of approximately 1/10. In addition, much healthcare improvement continues to be challenged by a lack of scaling, magic bullets and a lack of evidence (Dixon-Woods and Martin, 2016). Following the OBHC research theme, more boundary crossing is going to be needed by researchers and practitioners alike to help ensure ‘we’ know how to improve healthcare. It does seem that ‘we’, improvers and researchers, might have to change and become more sophisticated, not only in how we think and learn about healthcare improvement, but also how we practice it. To me it seems much more ‘surfing’, and many more ‘surfers’, will be required to cross professional, organisational/geographical and paradigmic boundaries.

When will we be opening the surf school?

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Spot the difference: QI and OD

Last summer, I asked Twitter users, what their views were on the difference between Quality improvement (QI) and Organisational development (OD) is and I followed it up in a blog. I promised I would write another blog about it… so here it is. This blog tries to summarise the responses I got, and incorporates some reflection from me.

Many responses to the question argued there is little tangible difference between OD and QI. For example, some argued that in practice it is hard to see a difference: action research cycles that inform many action learning sets and much reflective practice, also informed Deming when he developed PDCA, and later, PDSA; and that many variants of ‘change’ approaches have the same or connected roots. Other arguments included that both are about change and both are about working with staff to resolve issues, conflicts and problems to improve effectiveness; both seek to change culture and behaviours (eg see Toyota principle respect for people, and use of behavioural routines e.g. Leadership Kata); both have specific tools and practices… eg 5S, mapping, psychometric tests, and both most definitely use measures and measurement instruments; and both are capability development approaches.

Yet, many responses also pointed out differences, such as: differences in ‘who’ can practice OD and QI, and who ‘leads’ it; differences in emphasis on measurement, relationships and action; differences in views of culture and if it is something that can be intentionally changed, or if culture is something that mediates QI or an outcome of QI, or a combination. Some said OD is about change readiness and is strategic and argued that QI is about the tactical application of tool. Some also indicated there were differences in the view of, if a so called ‘good’ culture has to be in place before QI is used for it to be sustained and successful, or if culture is created as part of QI work; and there were differences in views about if ‘QI’ can be learnt through ‘training’ or if practice is ‘the only way’. Some pointed out that perhaps there is a different audience – staff for OD and ‘the customer’ (service user, patient, citizen etc.) for QI; and that different groups tend to prefer particular approaches, perhaps contraversially, arguing that there are the strong links between the nursing profession and OD and there are growing links between the medical profession and QI. Some responses indicated a view that OD is for people and relationships whereas QI is tools, measures and processes, revisiting longstanding tensions between perceived ‘hard’ (systems) approaches and ‘soft’ (people/culture) (Wilkinson, 1992). Finally, a number of responses said that QI is for efficiency whereas OD for effectiveness. (NB: I personally don’t agree with some of these arguments… especially the last two points).

For me though, a more interesting question might be: why do so many perceive a difference between OD and QI? Some of the responses I received through my twitter question included: professional protectionism; identity and power dynamics; a lack of measurable results from OD; and poorly practiced QI that focuses only on the application of tools with little fidelity to QI approaches, sometimes leading to OD practitioners having to ‘pick up the pieces’. A strong theme was a view that there is a narrow or limited understanding and conceptualisation of QI particularly by observers, (and from my engineering colleagues, a view that when observing lean / six sigma / theory of constraints etc. being used in manufacturing in practice, many have stereotyped engineers and just assumed only mechanical tools were being ‘practiced’, failing to notice the socio-technical approaches being applied ‘in full’). Finally, I wonder if to some extent the long term ‘split’ between so called ‘soft’ and ‘hard’ approaches to change underpins many of these views; and for some a continued lingering (and imho false) perception that many QI approaches are Taylorism reinvented, taking little account of more humanistic approaches.

A friend of mine, an OD practitioner, wondered if the difference was that QI was more specific than OD. That is, she wondered if QI is OD with a purpose… with language generated through different professional paradigms and there is strength from a combination of approaches that benefits patient care. At least, that was the only main difference she could spot, from her lens anyway.

What do you think? Can you spot the difference?

Please also note, I am most certainly not an expert here, and I haven’t read very much research in this area, particularly for OD. This is just a blog, I’m thinking this through, using the blog as a way of doing that.

Refs: Wilkinson, A. (1992) The other side of quality: soft issues and the human resource dimensions, Total Quality Management, 3: 323-9.

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Why does lean ‘fail’ in some healthcare organisations?

This was the question posed by Dr John Toussaint* on Twitter earlier this week.

Big question, and in my view the answers are probably as relevant to organisations outside of healthcare as those in it. It is also an important question, given the resources committed by organisations to ‘do’ lean, the opportunity cost of those resources and the potential learning from asking it, that might help us understand more about delivering value for patients effectively whilst being respectful of staff and the communities we serve.

So, what are my thoughts? Here are some of my reasons for lean ‘failures’ (in no particular order):

Rivers and rocks

You are possibly familiar with Ohno’s rivers and rocks analogy, where a cross-section of a river is used to illustrate how higher water levels hide rocks in a river bed and a lean approach seeks to lower water levels (inventory/waste) and in doing so the rocks become visible, allowing the rocks (problems) to be removed rather than worked around. The problem is, many seem to expect organisations using lean to have magically removed all the rocks by the end of day 2 or 3 and seem to think that problems and challenges thrown up through error identification and inventory reduction mean lean isn’t ‘working’.

Show me the money

Waste is removed using lean, in all its forms, transportation, inventory etc. But, these are not all cashable, and removing waste in itself, in healthcare anyway, tends to release capacity or reduce overburden, more so than reducing stock usage and wastage and thereby releasing cash. In industry, spare capacity can often be converted into revenue through the sales of more product on top of reduced costs from defect correction. But, in healthcare the use of fixed volume, fixed price contracts or fixed total spend across a population, can often mean this conversion is less possible for providers, meaning the only other way to turn freed up capacity into cash, (if this is an expectation rather than a safety, quality, morale or productivity gain), is through capacity reduction, thus potentially jobs. Who wants to improve themselves out of a job?

It’s too hard

It is hard, very hard at times. It’s hard to keep the energy, enthusiasm,when it at times seems so relentless, and after the initial full steam ahead, improvement can become a little more, well, boring. The attention to detail needed, the careful specific work to keep testing and adaption, the ongoing communication and influencing. It is easier to imagine sometimes to just go and do something else, something more exciting, with even brighter post-it’s or new gadgets and technology…. but then remind yourself why and it is worth it (but see reason number 5).

Leadership, leadership, leadership

Do I need to say more? The biggest risk for me, is when leaders, especially board level leaders lose interest, find other priorities, introduce another improvement approach on top of the lean approach confusing matters, don’t walk the talk, or find new jobs/retire without succession planning, not just for their role, but their successors role as well (if an internal appointment) and fail to find full sponsorship and understanding of the the lean work as they depart.

Why are we doing this again?

Perhaps the biggest reason, it fails simply because the organisation forgets why it was learning to be lean in the first place… to improve care for patients… and starts to believe their own hype and focuses on executing lean instead delivering value.

These are just my first thoughts, other reasons are failure to adapt to local context; too many initiatives driven through silos competing with lean; failure to respect staff and patients and improve together, too reliant on the internal/external change team; thinking lean is all about tools and training, failure to pay attention to organisational culture and so on.

I haven’t researched this area in any great depth, unlike Prof Bob Emiliani who has spent a good chunk of his career looking at the failure modes of lean. It is worth checking out his bookstore and blogs. What are your thoughts? Why do you think lean sometimes ‘fails’?

*Dr. Toussaint is the former CEO of Thedacare In Wisconsin, USA who set up and established lean there with the help of a number of folk using an adaptation of the Danaher business system, about 15 years ago. When I worked at Bolton FT on their lean programme, Thedacare was one of our inspirations and a group of staff went out to visit them and took part in some rapid improvement events with them. Dr .Toussaint has since set up the lean healthcare organisation, Catalysis.

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The neoliberal establishment

I first heard the word neoliberalism during an epistemology class as part of the first year of my PhD. I didn’t take much notice, frankly it was another long word that I just hadn’t heard before and in that class, it took quite a while to understand what any of the long words ending in *ism meant. Like yellow cars, however, I started to notice the word more and more, within student conversations, occasionally in an obscure journal paper, in the occasional Guardian article and increasingly on social media. This week I finally got around to reading ‘The Establishment’ by Owen Jones, which in many ways summarises a view of what neoliberalism is, how it has come about, implications and crucially who gains and thrives from it, and how they sustain it – the Establishment. He suggests that this isn’t some grand plan or group of leaders meeting in some smokey gentlemans club somewhere, but a mental model developed by a few outriders that prepared the way for a shift to the right, arguing that the post war consensus, i.e. The welfare state etc., needed reform and retrenching. As one of Thatchers children, the pattern was for me perhaps harder to notice, perhaps explaining why neoliberalism was I word I hadn’t heard before 2013, so normalised and prevalent were the arguments for privatisation and growing individualism, the need for accountability etc. during my education, early career and within general discourse.

Using this viewpoint, the book has made me think rather hard about what QI practitioners like myself do, and how that may or may not contribute to the ‘Establishment’ and what Owen Jones suggests it stands for. Quality improvement by its nature is about ensuring improved performance, measurement, and in many cases doing more with the same or less – many of the very thing that have grown during the era of neoliberalism. Some critics of quality improvement approaches suggest they just the latest in a long line of ways, most of which started, they argue, with Taylorism, to inappropriately standardise work (especially in healthcare) and exploit and control workers, gradually removing worker rights for flexibility and seeking ever more efficiencies and productivity improvements, that benefit the elite (establishment).

Most factories I worked in during my early career were on the brink of closure (often due to outsourcing activity, usually to Asia) or already in the throes of redundancies, which were often the programmes which I worked on to work out how a supply chain could keep working whilst production moved or the workforce downsized. The first time I work on a project involving redundancies I remember having a huge strop with my boss explaining how ‘I came to improve things, not help people lose their jobs’… I was sat down and it was explained to me that in the long run this was better, because without the restructuring there would be no factory at all, and surely some jobs are better than none. At the time, as a junior engineer, I just nodded and got on with it… time to grow up, it was my job, right? And I continued to work on improvement projects of all types. I do remember a sense of relief though on joining the NHS that now I would ‘definitely’ be improving people’s lives.

But the perspective offered in this book has really made me wonder if we are doing what we ostensively set out to do when improving quality in healthcare. Most improvement approaches define quality based on the patients view of quality (a few could be argued to use much more neoliberal view…i.e. stuff people will pay for). So, how much of improvement activity is genuinely for patients? How much improvement activity is genuine coproduction and working together with staff and patients? This to me is the hope that is offered by quality improvement approaches rather than the exploitation and standardisation that QI approaches can be critiqued as. My sense in healthcare is we are not there yet, and have quite somewhere to go.

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