Continuous improvement with the 'improvement chart'

When we our lean journey in the St. Elisabeth Hospital en we read about 'continuous improvement' we first thought that it implied that we will be running much more improvement projects. We have come to understand that Toyota acts very differently. At Toyota everybody works continuously on improvement. Put differently: improvement is part of your daily work. You perform your activities to create value and you think about how you can do it a little bit better tomorrow.

Which methods support this? Toyota uses many methods, but one of the most well known is the 'andon''  chords. When someone sees that a process is not performing as it should, they pull the chord. A specific music starts to play and several people come and analyze on the spot what the problem is and which countermeasures can be taken to prevent it to occur again. At the picture the arrows point at the 'andon' chords.

This is difficult to apply when treating patients. We can't just stop the care process (or maybe we can, but at this moment it is hard to imagine). That's why we embraced an instrument that has proven to perform a similar function very well in our hospital: the 'improvement chart'. The picture below shows an example of the improvement chart on the Neurosurgery ward.

The chart on the picture is in Dutch. The headings translate in to:
- Date
- Problem
- Countermeasure
- Action: who does what?
- Evaluation date

The method is:

• When someone can't perform his or her work as it should be, he or she writes it on the chart. E.g. this patient has been twice to the ED and has been treated by two different neurologists. I need to book a follow-up appointment, but I don't know with which Neurologist.
• Every day or several times a week the whole team gathers at the improvement chart for 15 minutes. People who wrote on it explain the problem. There is a check: is the problem clear?
• The team discusses the cause of the problem. Do we understand why this problem occurs?
• The team discusses possible countermeasures. What can we test to prevent this from occurring again or what can we agree so that the next time we know what action to take?
• The team decides who does what and when they will evaluate the effects of the test.

The decided actions of the former discussions are reflect on:

• Those who too actions tell the team what they did. The team evaluates the effects they have experienced and decide whether the new way of working becomes the new standard or whether further tests are needed.
• If it is the new standard, it is removed from the improvement chart and on a second chart, the 'This is how we work' chart,  the new method is written down. If relevant, it becomes a procedure ow work instruction. It is also noted on a digital chart so that later all improvement activity can be reviewed.
  
• periodically the team evaluates the improvement chart and discusses which theme's keep occurring on it. They can decide themes to improve on.
  

The underlying principles correlate with an earlier blog: 'the art of making things small'.

The first improvement chart was tested in October 2008. One year later there are over fifty improvement charts in use in our hospital, in every type of department. Almost every week a department requests support to also introduce it in their teams. Apparently it addresses a strong need and appeals to the teams.

We also learned that about a third of the teams struggle to use it well. They sometimes tend to make problems big, turn the improvement chart in a complaining chart and consequently don't see enough progress. They sometimes don't have (nor create) enough time to work on improvements. Sometimes they lack the skills to apply the method thoroughly.Sometimes also they chart is to isolated. If the team works too much on improvements that are not a priority for the department, the support diminishes.

Despite these problems, the improvement chart is very popular and clearly the most applied instrument in our lean journey untill now. It's indicative that it spreads itself by word of mouth.

The chart enables teams to draw problems into their sphere of influence. By visualizing problem and having a format handle them they become much more productive in the improvement efforts. They experinece it as an intuitive method. Improvement indeed becomes a normal part of everydays work.

Lean thinking and compassionate care

Recently O&I published an interview (in Dutch) with Jacob Caron, Orthopedic Surgeon and chairman of the medical staff of the St. Elisabeth Hospital in Tilburg in the Netherlands. Jacob talks about the relation between 'lean thinking' and 'compassionate care'. A reflection on several quotes using the 14 principles of The Toyota Way.

"...it's typical of 'lean thinking''  not to think from big, future plans, but to initiate change process from problems and issues in the current processes. By staying close to the existing processes, changes are kept small."

Principle 5: Build a culture of stopping to fix problems, to get quality right the first time

Fixing problems directly can only be done by the people that encounter the problems. That implies that every team member considers improving a normal part of every days' work. By keeping lean thinking small you bring it into the zone of influence of teams.

"... this approach creates a deep learning process that leads to sustainable change, because the change process does not limit itself to fighting fires, but is aimed at adressing the root causes"

Principle 14: Become a learning organization through relentless reflection and continuous improvement

Relentless reflection is confronting. Our (health care) culture tends not to show that you have a problem. To learn deeply, people need to be able to make themselves vulnerable so that root causes can be addressed and more fundamental change processes can take place. Trust is a basic condition. To create a culture of trust is very demanding of leadership.

"...it's important to anchor the 'lean thinking' philosophy in a long term vision on excellent care. This vision must include the core values of the hospital and gives direction to the process of continuous improvement that 'lean thinking' initiates. The St. Elisabeth Hospital chooses as a core value: 'compassionate care'.

Principle 1: Base your management decisions on a long-term philosophy, even at the expense of short-term financial goals

The long term philosophy will need to be so well connected to what the hospital stands for and what the environment needs that it will also provide direction in difficult times. In good times buffers need to be created that enable to hold on to the principles in the more difficult times.

It might seem contradictory that the earlier quote he stated that lean thinking does not start from a big future plan, and here he states that a long term philosophy is important. The difference is that, for me, a future plan is not value drive, but control driven. It's oriented at what is not. A long term philosophy is based on values and that provides direction to take decision in the here and now. It's oriented on what is. A future plan takes away initiative from most and gives it to a few. A long term philosophy can and increase initiative.

"Administration and leaders must stay connected to the primary processes and let that feed the vision."

Principle 12: Go and see for yourself to thoroughly understand the situation

Going to the source to base decisions on observations and experience from the work floor. This is extra difficult in health care, because many actions literally take place behind closed doors and because many steps are not taking place right after another (and many should not be). That makes it the more important to do effort to go to the source in health care. For example by attending daily or weekly (short) gatherings of teams that reflect on the day or week.

"In summary, 'lean thinking' creates space for compassionate care if the change process is anchored in a long term philosophy on excellent care. Compassionate care is part of the core value that is being optimized with 'lean health care'."

Principle 1: Base your management decisions on a long-term philosophy, even at the expense of short-term financial goals

"You need to understand your patient, what he wants and expects. Try then, each time again, to meet that expectation perfectly."

Principle 14: Become a learning organization through relentless reflection and continuous improvement

By connecting the first and the last principle it becomes full circle: relentless reflection on the way value is created, related to the changing expectations and values of patients, feeds the continuous, steadily improvements to deliver better value.

Pitfall of lean

Lean is one of the most widely used and proven management approaches. Yet, also with lean applications there are many organizations that do not achieve a real lean journey. Projects might deliver results, but they rarely lead to a sustainable development. After a while the attention drops away. What are the pitfalls of lean? A first exploration.

What characterizes the (popular) literature on lean? The approaches are largely based on a rational, predictable approach to organizations. Read the most common lean method another time:

1. Determine value
2. Identify the value stream
3. Create 'flow'
4. Let the customer 'pull'
5. Continuously improve
(Womack en Jones, Lean Thinking)

Step 1. Determine value
Could it be that different caregivers often think differently about what is of value to a patient? And that patients themselves have a completely different view? Hoe do you handle a great diversity of views? An example:

A department realized that they offer a poor service by giving their patient their date to be operated just shortly before the operation. Therefore they started a project to offer every patient their operation date directly in the outpatient clinic when the operation is decided. A nice improvement. Yet something felt not right. A later study showed that 95% of the patients indeed highly appreciated the new service. 5% however is very nervous before the operation and can't sleep anymore as soon as they have the date. They prefer to be called as shortly to the operation as possible. Determining value is often more nuanced than at first glance.

Step 3. Create 'flow'
Could it be that many forms of waste are related to historical patterns and relationships? That it can be threatening when this is analysed? Or that in itself rational process improvements create uncertainties for stakeholders? An example:

An outpatient clinic had problems with no shows, pressure of phone calls from patients and GPs requiring priority, much work with rescheduling sessions, and surprisingly enough, also many unused appointment slots. A major cause appeared to be that they used various types of appointments on fixed times in the sessions. E.g. always a new patient at 9am, 9.40am, 10.20am. This offers insufficient flexibility because every week there is a different numer of patients requiring a specific type of appointment. Just stop using fixed slots and plan flexible. The group of doctors however did not allow this. Why did they use fixed slots? Because they wanted to be sure that every specialist sees an equal number of new patients, thereby ensuring that each specialist contributes the same to the group. This had gone wrong in the past. From a flow perspective, the current planning method is a (minor) disaster and there are other solutions, but they would not let go because they feared that the old quarrel would come back.

Step 5. Continuously improve
What are your experiences when you suggests an apparantly good idea? Is it often not put to practice as quickly as you can imagine? An example:

On an outpatient clinic the relations had gone from bad to worse. There was much dissatisfaction. They saw many things they did not like, but they were not able to improve them. Interviews revealed that the assistents perceived that the specialists hold all the power and blocked any improvement. The specialists however said they had many good ideas, but they needed the assistants to realize them. Since the specialists did not have any formal power over the assistents they were not able to influence them. The specialists felt powerless.

With a sense of reality
The examples are not intended to indicate that the lean principles do not apply there. To the contrary. Lean however pays little attention to the non-rational side of change processes. Even thoug they often determine the progress. In the words of Marcel Boonen, manager of a care department: "after the logic starts the confusion".

With a lot of external pressures (higher management, program management, etc.) the rational approach can deliver results. Continuous improvement, a cultural change is something different. Lean thinking can not be implemented. For the non-rational side, to reach inside, other interventions are needed. This starts with the recognition of different views on value and problems and investigating them with a sense of reality. As a secretary once spontaneously shouted during an improvement session:

Do you mean that from now on you are going to take our ideas seriously!?