‘Which improvement approach is best?’

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Without doubt, this is the question I have been asked most during the last 4 months since returning to paid up employment:

‘Which improvement approach do I think, is the best?’

I find it sometimes a tricky question to answer, because it can reveal so many different things, which depending on the context, I don’t always want to reveal.  It can potentially reveal information and clues about my professional background, and potential tribal allegiances, about my view of improvement priorities, my perspective of ‘how’ to do improvement work: top down or bottom up; frontline or corporate centre; clinically-led or patient led, internal team or external consultancy; my knowledge and experience and even my view of the world.

My view has changed.  I did used to think that…. or kind of think that, Lean was the best approach.  I think gave that impression. Not in the way many view Lean now mind, codified as: value, value stream, flow, pull and perfection (perhaps Lean has even ossified like this?).  But as both continuous removal of waste AND respect for people and society rather than any tools or techniques.  With 4 True North goals, Lean’s version of the IHI Triple Aim: quality, leadtime, cost and morale. Those to me were common to most ways of respectful problem solving, and in a way, just how you were taught to think and work as an industrial engineer and improvement leader.  Choosing the way of solving the problem and selection of the best ‘approach’ part of the skill set for each problem and context.  Sadly, I see Lean often ‘defined’ and ‘practiced’ in very mechanistic and inexperienced ways, where arguably ‘over-standardised’ tools are used [e.g. office based ‘sterile’ 5S] to ‘make it easier’, where money and results dominate whilst customers, service users (patients), people and society are barely mentioned.

When I came into healthcare I found it very confusing: why is there so much debate about which improvement approach is the ‘best’, (I don’t remember this debate in any earnest in industry), why does there seem to be so many arguments, aren’t they all really the same underneath?  With a focus on the customer (service user, patient), emphasis on flow and reducing variation and a requirement to support those doing the work, to improve the work?  [And as an experienced industry improvement professional what the h*ll is this newfangled IHI-QI approach, that doesn’t seem to be used anywhere else but healthcare, and yet seems broadly the same but just with different jargon, coupled with loads of clinical terminology and metaphors?, Yes, jargon barriers work both ways, folks.]

So what is my view now?

I suppose I have mellowed and take a view that there are many benefits of using different approaches in different circumstances, though I think it helps for improvement beginners to just use one at first, with all its jargon and peculiarities, (whilst signposting it is not the ‘only or best’ one).  I consider that learning and practising more than one overtime also important, to learn the strengths and weaknesses of each, to develop some level of mastery, to be able to cut through and translate the jargon, to recognise that the seemingly different tools and techniques on the surface in look and name, are similar in usage and to learn when and why some suit and some don’t (often through failed tests of change) in different contexts, cultures, organisations and sectors whilst working collaboratively across a supply chain (or care pathway).    

All of the approaches have strengths which can be helpful in different circumstances: lean in reducing lead time and its relentless focus on the flow of value, together with a blueprint for a ‘management method’ for organisational or system improvement; IHI-QI for its collaborative method and ability to engage folks in improvement activity; 6sigma for its focus on variation and product/process consistency.   The approaches, to me, seem to have similar ‘tools’ for similar tasks, such as the Model for improvement or the lean A3; the driver and fishbone diagram; patient safety walkarounds and gemba walks; collaboratives and yokoten (translates as horizontal deployment); to name but a few.  These improvement approaches all also have plenty of downsides, not least the lack of evidence of their effectiveness, regardless of approach chosen.

However for me, the strength of improvement approaches is in their similarity in helping folks solve problems and serve their service users and patients better. Consistency of purpose in improving care, rather than consistency of approach seems to me to be more important, (although I am mindful of potential fidelity problems). I prefer to put my energy and passion in to the ‘doing’ of improvement for this purpose, rather than using energy considering which improvement approach is best.  What’s your view?

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