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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About joyfurnival

Interested in TQM, lean, Quality Improvement, Healthcare, Regulation, Accreditation, Inspection Improvement Science, QI, improvement capability.
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