Reflections from OBHC – finding a research community

Earlier this week, I was lucky enough to attend the 10th International Organisational Behaviour in Healthcare Conference (OBHC) held at Cardiff University Business School, which was focused on ‘Attaining, sustaining and spreading improvement: Art or science?’.  I had submitted an abstract for an aspect of my PhD work and was pleased to receive feedback and be invited to present at the conference, though nervous at the same time, and my supervisors both encouraged me to attend.

When the programme was published I was pretty excited about this conference. When reading for your PhD, often the same authors of papers pop up repeatedly, particularly when highly cited, and it seemed to me that attending this conference with me, would be many of the ‘academic celebrities’ whose work I have been studying.  And not only that, but some of my friends from the Health Foundation PhD programme; together with faculty from the ‘GenerationQ’ quality improvement leadership development programme, which I completed in 2010, would also be there, presenting their research linked to the programme.  Without them I would not have been doing a PhD at all, what a way to re-connect.

Photos: Academic Speed-dating (credit: @cjpope on Twitter); Health Foundation PhD Award colleagues at Cardiff Castle with myself and and beautiful outdoor shot at Cardiff Castle (credit: @emmajonesphysio on Twitter).

Prior to the workshop there was a day set aside just for early career researchers and PhD candidates. This session was wonderfully facilitated by Professor Catherine Pope from Southampton University, who told us transparently, that she would shout at us repeatedly until we did what she wanted – which was just as well given the decibels we created later. It involved over an hour and a half of ‘speed-dating’, when all of us got to talk to a different person for four minutes each time about our areas of research and interest, and in case we needed an ice-breaker – what we were fearful about.  This is how the decibels were created, it was outrageously loud!  Yet fascinating and fun at the same time, and a great way to put names to faces and a way of meeting each other quickly, and facilitating coffee time chats, networking and reflections throughout the conference.  That evening we were also treated to an exclusive tour of Cardiff Castle together with prosecco and canapes, lovely….  a change from PhD Life!

The following day the conference opened with a keynote from Mark Drakeford, Minister for Health and Social Services in the Welsh Assembly Government. He outlined a fascinating perspective on ‘Prudent healthcare’ in Wales describing a health and care service where professionals ‘only do what they can do’ rather than trying to do it all.  Other intriguing keynote speakers included Professor Stephen Shortell and Professor Louise Fitzgerald, who both commented on improvement, transformation and change with differing perspectives, reminding me so much of the value of differing theories to help see issues in a new light and to help create new spaces and opportunities for improvement in healthcare, both as a science and as an art.

The conference seminars were absorbing. There was so much opportunity to learn about differing aspects of healthcare organisational behaviour such as knowledge mobilisation, nursing care home operations, innovation and improvement processes, governance, brokering change, submitting to academic journals and many other areas -all also linked to healthcare improvement and change.   These sessions were also a great way to be introduced to new areas of literature and theories that I have not yet explored.  My presentation session related to regulation and governance and I was delighted to hear about other work in the area and feel welcomed as part of both that specific research community and the OBHC community at large.  I also valued the feedback and recognition for my research as part of my thesis which can feel like a lonely and vulnerable way to travel at times.

From my perspective, the conference was an overwhelming success at developing research and researchers and providing a place for respectful challenge and support for a community wanting to use research to understand and improve healthcare. Well done to those from OBHC, thank you for welcoming me into your community, and my particular thanks to Dr Aoife McDermott, from Cardiff Business School, whose research I am building on, and who not only encouraged me to submit an abstract but also supported me hugely through the conference in many, and some unusual, ways.

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How not to be lean

How not to be ‘lean’

Last month an opinion piece was published in the prestigious New England Journal of Medicine decrying lean or ‘medical Taylorism’ and arguing that amongst other things that approaches used to standardise care have gone too far, and it is time to remember the patient, and the perennial favourite reason of ’we don’t make cars…’.

Needless to say, in the lean community, there was a bit of a to do! (see Mark Graban’s fab thread and comments here). Not only was it perceived that the authors were incorrect to say this as the criticisms are surely about ‘fake lean’ not ‘real lean’, but also that they compared lean and Taylorism to be the same thing.  Ouch! How to hit the lean raw nerves!  Though there are plenty of things to learn from Taylorism.

Now this might be a controversial opinion too…but some of the criticisms in the article of lean (in this case in US healthcare) are surely familiar to most of us in the lean community? They are not new, and whilst some of the statements in the article may be inaccurate, if we are all truly honest I doubt that any of us have NEVER accidently fallen into the trap of some of them.  Maybe it happens whilst we were learning our practice or at times of immense pressure – we are all human after all.  (At least, I hope it is not just me!). I believe it is time to be more reflective and honest about when and why ‘fake’ lean practice sometimes happens, either unintentionally or intentionally because then, we can think about what we can learn from that, and what we can do to change the situation.

So, taking a deep breath, here are my five ways of not being lean.  These are my reasons (excuses?) for unfortunately practicing ‘fake lean‘, from my experience in both industry and healthcare… Needless to say, there are probably a load of other reasons too…maybe I’m not brave enough to own up to all of them yet.

Wanting to be the Expert / Lack of Humility

As a graduate industrial engineer….I thought I was special and very knowledgeable ‘a lean expert’, I have a degree in this for goodness sake.   I thought with all the exuberance of youth that being lean would be easy.  I thought hey I can apply these principles that I have learnt about lean production in automotive in the process sector, no bother, it will be easy.

It wasn’t, the context is hugely different, different production processes, different cultures and different products. As ‘an expert’, it is easy and arrogant to think, I have seen this type of problem before, and I remember the solution from that and go and implement it, then I’ll save a load of time and bother.  It requires much more effort and humility, to listen, observe and talk to those who do the working or ask for help.

Money, Money, Money

If lean is a way to improve quality, remove waste, add value and ensure respect for people and society, why in business cases and sales pitches does the ‘return on investment’ and just how much money can be saved through lean always seem to be the main emphasis?  Often closely followed by a long list of all the ‘lean tools’ that will be taught. On reflection, I think perhaps it is fair that an organisation might think that lean is about money and tools, if that is how lean is ‘sold’ to them, particularly if gain-share contracts or similar are involved.  That lean is often perceived as a money saving tool is arguably a product of our own making.

Sticking to objectives / Silo Working

Understanding the history of the organisation and why they are in the position, and how that came about, to me has become critical. Once, I worked in a factory implementing a number of lean cells with huge improvements in inventory and lead-time reduction leading to improved cash flow, improved workforce morale as expected.  However, the financial position of the business was so precarious, the factory still closed, partly due to the financial impact of the inventory reduction activity.  A more careful understanding of the wider picture may have developed a more nuanced plan and been more respectful and careful about managing expectations with employees.

Further, few organisations I have worked with have not tried some variant of lean or similar (six sigma, lean six sigma, IHI-QI, agile, TQM, CQI, TPM, TOC, BPR, BPM, LiA etc etc). For me now, understanding the story of previous attempts to use progressive management practices, is critical to developing new ways of working and change in that organisation.  In addition, I find it now vital to understand the wider commercial and regulatory environment, as well as customer needs and notice if this is changing, to allow adaptation in improvement solutions and improvement/management system if needed.  For certain, I never used to take enough notice of this….maybe I still don’t take enough notice.

Lack of Courage

Sometimes, in my experience, it is hard to gain traction or commitment for a change in working practice, for so many reasons.  Often it is worthwhile to enquire more into the source of this problem.  Sometimes, it is easier to back away from this challenge and do something else, and rarely positions are just entrenched.  Sometimes, it is easier to ‘just do something’ that you know is not in keeping with lean principles, because of the pressure to act and to be seen to do something.  Sometimes cutting corners is enough, reducing the fidelity of lean practice (watch that pressure to make an A3 easier to fill in and reduce ‘the paperwork’).

Sometimes, these things might happen to just keep face, to continue to be accepted by the organisation, or even wanting to keep your job and not be seen as a troublemaker or lose a trusted advisor role.  Many of us do not have the financial security or position of being able to walk away from a role or contract and accept some of the compromises.  This is the art of being able to ‘rock the boat and stay in it’. Sometime, I’ve also ‘rocked the boat’ too much, and fell out of it too, this I find, is as hard to live with, as rocking it too little.

Taking comfort in the Status Quo

One of the great strengths of lean is the development of standard work and having the self-discipline to stick to it, because it has been tested to be the best known way of working. Thing is, it doesn’t really stay the best known way of working for long.  Sometimes, not too often I hope, I have found it easier to keep working with improvement teams and clients encouraging them to improve in the way that I have always done, than find the time to change myself and my standard work, leading me down a route of outdated practice and that no longer fits the local working environment and context.

So, five areas of practice that could be interpreted as ‘fake lean’ and reduce my credibiltiy as a lean practitioner.  My view, I am always learning and I need to reflect on when these things happen, to recognise the patterns and think about how to act differently the next time those situations may occur or are occurring so I can maybe change the outcome for the better.

On reflection though, there is an air of familiarity to these reasons/excuses.  Are not these just the kinds of problems that organisations we work with typically have too?  So, what are the processes we use to help them with these problems, and how as a lean community are we going to use them to improve what we do?  How are we going to stop not being lean and reduce the prevalence of ‘fake lean’?

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A Brief Guide to Article Writing for the Young Researcher


Photo credit: Nic’s events on Flickr

Invited author: Jeroen van den Bergh

ICREA Barcelona, Universitat Autònoma de Barcelona & VU University Amsterdam

Editor-in-Chief of Environmental Innovation and Societal Transitions (EIST)

A clear and attractive journal article requires a great deal of preparation and self-criticism. Even obviously talented writers will admit that it takes as least as much perspiration as inspiration. One can find many opinions on how a good article looks like. Here is my two cents, based on experiences as (co-)author, thesis supervisor and editor. The reader is reminded, though, that whereas a set of writing suggestions is useful, variations on these can make readings more appealing. So take my advice with a grain of salt.

To begin with the end, circulate your paper among critical but constructive colleagues, and persistently revise, revise and revise. Aim for revisions to render shorter instead of longer texts. This will assure…

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Learning Lean

A friend of mine, published this diagram today on his Facebook wall.  (I’m not sure where it is from or who developed it, but it seems to be linked to ‘Big Up the NHS’, apologies if I have that wrong).

It compares South Tees Hospital in the North East of England with Virginia Mason Medical Centre (VMMC), in Seattle who have been contracted to support NHS improvement in England to learn about and implement lean healthcare.  You might notice the scale differences in terms of volume and bed numbers between the two organisations in the example, not to mention the geographical difference.

When I first heard of the potential deal with Virginia Mason Medical Centre (VMMC) and the Trust Development Authority (TDA) to support the implementation of lean by way of the Virginia Mason Production System (VMPS) in a number of trusts in England; my first reaction was; brilliant, how can I get a job in one of those Trusts? (post PhD obvs!) What an opportunity.   My second reaction a few moments later was, similar to the diagram above was why VMMC? They only have 300ish beds and they are on the other side of the world. How will their challenges compare with Leeds Teaching Hospitals or other large hospitals like them (such as South Tees) or indeed any of the other organisations selected to take part (Surrey and Sussex Healthcare; Barking, Havering and Redbridge; Shrewsbury and Telford; Coventry and Warwickshire)?

VMMC has a well-deserved reputation, steady leadership, some research evidence of their work, results and a steady stream of visitors from the UK (I wrote about Jeremy Hunt’s visit here). They have lots to share and lots for us to learn from, great safety work; the compact and what lean leadership looks like, oft quoted results; so in many ways they are an excellent choice. But a little niggle started in my brain, because there are many healthcare places doing lean and reaping the results or otherwise, and learning from when it goes well and when it goes not so well…. Does we really need support from Seattle? From an organisation with only 300ish beds? Really? Does their brand, results, knowledge and reputation mean that much?

For example, why not Thedacare in Appleton, Wisconsin,  again not so many beds…but does size really matter, to learn about learning lean?  They have the Thedacare Centre for Healthcare Value to help share the learning or we could learn from those involved in the much bigger lean healthcare work in Saskatchewan province in Canada. Who else is there? There is the ubiquitous IHI….ok so they tend not to use lean as their overriding approach, preferring a more purist Deming approach to improvement science. Still, they are overly qualified, have a superb reputation, and could do the job. In addition, they have a track record of helping healthcare organisations, e.g. in the NHS in Scotland with some lauded results….and importantly, at scale. However, all these examples still need a few trans-Atlantic flights and there has been little rigorous and independent evaluation. That has not to say we should not learn from the USA, we must pinch with pride the best ideas, approaches and learning to improve care.

VMMC has a record of improving financials, as well as safety, notoriously more difficult to demonstrate in healthcare. Maybe this has something to do with the choice, given that the financial performance figures for NHS English providers in the first three months of this financial year show a deficit of £930m in Q1 of 2015-16 – bigger than entire deficit for previous year. But then….for lean organisations, financial improvement is the expected by-product of quality being ‘free’ rather than the aim….so I truly hope deficit reduction is not the ‘major’ evaluation criteria for if these lean healthcare experiments ‘work’….(I hope there will be evaluation….!)

In Europe, there is also a lot of learning about lean healthcare… an awful lot more than there was a decade ago. For example there is the work and learning from the large scale roll-out of Productive Ward (based on lean developed by the NHS Institute for Improvement and Innovation, ex-Toyota employees management consultancy KM&T and McKinsey), some of which is captured in this evaluation about Productive Ward in Ireland. There is also learning, experience and expertise for sharing from those who have attempted lean work in healthcare and discovered just how hard it is in a NHS context, not just a healthcare one. Places such as the Wirral, Bolton, Stockport, Blood and Transplant, the Lean Healthcare Academy, Portsmouth, Barnsley, Calderdale, Blackpool, the NE of England, with the North East Transformation System (also developed through a relationship with VMPS) and many more both within healthcare and outside. There is as much learning from these NHS organisations and their staff on how not to do lean healthcare and what ‘fake’ lean looks like as there is about what do to well and how to integrate it with other quality improvement work and governance. (Including at Leeds actually, who worked with KM&T for quite a while doing lean work and so I hope the VMMC work will build on top of this initial work and learning). In addition, there are numerous UK based academics and management consultancies who can help.

Thing is, whilst knowledge, expertise and experience is helpful, in a way it does not matter who comes to help, or from how far away, or what their organisational configuration or size is; the external support cannot do the work, and they cannot guarantee success. Only the organisation and its stakeholders, patients, employees, commissioners, regulators can learn to change themselves for the better and have the tenacity, resilience and persistence to keep going in their context. I feel that much of lean is learnt through doing. The external support whether it comes from the other side of the world or round the corner can only facilitate encourage, coach and create supportive environments, not do.

An organisation on a lean journey is likened to a climb up Everest with the organisation encountering many problems on the way and many opportunities to turn around and tempting chances to change course.  Even with help to carry your bags and plan your route, you still have to climb up yourself, no one else can climb for you and no-one can control the environmental conditions and weather.   A lean transformation might take over 20 years in some of these very large NHS organisations. It may be very easy to become impatient and slip into the delivery of LAME/Fake lean, even unintentionally, or in reaction to urgent stakeholder demands, or whilst facing new pressures such as organisational reconfiguration or financial or reputational ruin or as leadership intentions and strategy changes. Some might even do lean as the latest policy fad, waiting for the contract with VMMC to be over and move on to the next new ‘improvement’ fashion or return to less progressive management methods.

I truly hope these five English NHS organisations can stay the course, even as people change within the organisations and within their stakeholder groups and as policy continues to evolve. This huge lean healthcare experiment offers opportunity of a lifetime to learn from VMMC, one of the best, and learn how to scale and adapt what they have done in a 300ish-bedded hospital in Seattle for their own organisations, wherever they are in England and whatever size they may be. This will not only support the delivery better care for patients, but more importantly support the organisations to learn how to keep adapting lean for their context and delivering safer and better prevention, care and support for patients and the public in the future in a self-sustaining way. Hopefully, they too will then inspire and support other aspiring lean healthcare organisations, even if they are the other side of the world or sized differently to ensure even more patients benefit. This, for me anyway, is the long-term promise of learning lean.

NB apols for those links that are £walled

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Three generations of surgeons, born in the wilderness by @fanusdreyer



Olifantshoek is a small town in the south-east corner of the Kalahari desert, in a “poort” where a seasonal river flows through. Seasons here are measured in years or decades, not months, but there is enough water so that the town dam only occasionally runs dry. In the Northern Cape and southern Namibia children regularly get to school age without ever having seen rain. In the 1920’s my grandfather was the Dutch Reformed minister in Olifantshoek.

One day in 1922 granddad travelled to Bloemfontein for the church synod. He was a bit of a technophile so he was one of the first in the region to own a car, although he did his parish visits on horseback due to the roughness of the terrain. After the synod he gave a lift home to a Rev Brink from Danielskuil, another small town on the edge of the Kalahari. They got…

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Good Cop, Bad Cop – Can a healthcare regulator be both?

I have had another blog published on the Policy@Manchester Website

It is about the changes for TDA and Monitor (English healthcare scrutiny organisations) becoming NHS Improvement, and from my research so far, what I have learnt that could benefit regulators who are both scrutinising and improving.

You can check it out here:

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Patient Safety is hard

suzette woodward

Its time we stopped beating ourselves up.  Patient Safety or improving the safety of patient care is hard. In today’s world we have spell checkers and prompts to help us with difficult problems.  We have search engines which help us find the most obscure and wonderful facts and figures.  There are even designs that help us get things right; large handles to pull a door (rather than flat plates to push), cordless kettles, brakes and accelerator pedals in the same place on every car.  But for many problems in life and in particular in areas like patient safety there is no easy solution.  So what are some of the things to consider?

expertise – we really should be respecting patient safety as a science that needs scientists – a person who is studying or has expert knowledge of one or more fields.  But with very little on offer to help people…

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