The art of making things small

There are different ways to improve processes. 'The art of making things small' refers to the choice to reach your goals in small steps. This relates to principle 14 of the Toyota Way: "Become a learning organization through relentless reflection (hansei) and continuous improvement (kaizen)". Why would you want to make things small? Because a pitfall of projects is that we discuss for weeks or even months before anything changes. The  risks with this approach are:

• The longer it takes for the first change to take shape, the more people who experience the problem loose faith that it will be resolved. The support for any change crumbles.
• Many of those who perform the work in the process where the problem occurs are not involved in the thinking process. This means that you need good communication (which is often problematic) and often the much feared 'resistance to change' starts to take shape.
• The solutions are developed separate from the work floor, separate from the (physical) place where the problem occurs. That means there's a real risk that the solution will not exactly fit the complexity of the situation where it's supposed to work.
• Perhaps the solution will be piloted, but by now those who are in favor of the solution have argued for weeks or months to promote it and they now have to prove that it works.They have connected their personal reputation to the solution and will not like to see that it fails. Those who are not in favor of the solution hope that it will not work, they might even influence the results of the test to make it not work. Will this be a good test?

Recognizable? I have seen this happen over and over again. The art of making things small is a method that approaches it very differently. It is based on the teachings of Roger Resar on Reliability. The essence is simple: reduce changes to a size that you can literally test tomorrow. A team can use the next steps do achieve this:

1. Define the process where change is needed.
   For example: it takes too long before general practitioners receive the letters form the specialist about the results of patients.
2. Describe the process in four or five steps.
   For example: appointment - dictate letter - write letter - send letter.
3. Define where a problem occurs. If necessary: describe this step in four or fives steps.
   For example: time between appointment and dictating takes too long.
4. Define a change that you can test tomorrow. Choose the most easy circumstances for the test.
   For example: one specialist will dictate one letter for one patient right after the last appointment on the less busiest day of the week.
5. Evaluate whether the test worked. Just yes or no. Evaluate why it did or did not work. Define the next test.
6. Keep on testing the idea or new ideas until a good countermeasure has proven itself in practice. Make this the standard new way of working.

To solve the complete problem of the total throughput time, the time between the appointment and dictating is probably only part of the problem. There are likely to be multiple causes. The idea is that more then one test run simultaneously. If a team is experienced, four tests can run at the same time, each test lasting one day or week.


Except addressing the risks as described above, there are other reasons to apply this method:

• By making changes smaller, they are pulled into the sphere of influence of the team. They can achieve more changes themselves.
• There will be more learning. Learning by doing is more effective.
• Decisions are more based on facts, more based on experience. Opinions and emotion become less influential. 
• Changing becomes more fun, because the people that undergo the change decide and evaluate the change themselves. There is more ownership, more pride.
• Less time is spent on meetings.

This method is based on the 'plan-do-check-act' cycle of Deming or perhaps more accurately from Shewart. Reread the six steps above to recognize them.

There are also pitfalls with applying the art of making things small:

• Not enough analysis why there is a problem
  Suggestion: you do need an understanding of the cause of the problem. Often this is clear enough and you can start testing directly. But sometimes you do need further analysis to assure that you are not addressing aspects that are not relevant to the problem. 
• Not enough coordination of the tests. The team goes testing changes without keeping track of the effect on the problem that needs to be solved.
  Suggestion: keep going through the complete cycle (see above). Not only for each test, but for the complete problem. Someone is responsible for the coordination (the owner of the problem).
• Reluctance to start testing because the person that does the test is not convinced it will work as the new method of working.
  In the example the specialist might not want to test dictating directly after the session for one patient, because she expects it might work for one patient per session for one test, but not for all patients every day.
  Suggestion: test anyway! Doing a test is no obligation to keep doing it, also not if it works. You can only judge whether the idea is feasible after the test. Then you can decide based on facts instead of imagination. More importantly, doing the test can lead to a better idea that is feasible.

Achieve great things by making them small!

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.

Never try to change something

One of my favorite statements is:

"Never try to change something if you don't love it as it is now"

What drives you to change something? What is your motivation?

When your make a statement about something that you want to change (eg waiting in a department or the willingness to help each other), do you disqualify the current situation? Do you speak about how it should be, without a deep understanding of why it is as it is now?

Lean thinking is based on systems thinking, which comes down to:

"Every system is perfectly designed for the results it gets"
(Paul Batalden)

If the results are not good, what is the cause? Improving results requires insight into why the current system performs the way it does.

Principle 12 of  The Toyota Way (as described by Liker) is:

"Go see for yourself to thoroughly understand the situation (Genchi Genbutsu)"

A common strategy used in change management is to make people very dissatisfied with the current situation. To make it clear that everything is bad and that everything must change. The jargon for this is 'to create a burning platform'. Then people will have to jump.

When is that a wise strategy? Cetrainly not if you want to improve the way Toyota does. Perhaps it is wise if the current system is so sick that you need a radical change? I doubt it.

Each organization that exists over a longer period has values that under the surface that establish cohesiveness and provide continuity. In terms of Teun Hardjono: that feed the intellectual and social capabilities of organisations.

A burning platform gives momentum for change, but usually the baby is thrown out with the bathwater by also disqualafying what is good.

A deep understanding of the current situation clarifies why the current approach does not lead to the value that you want to create together. In there lies, often dorment, the motivation for every careprovider to do things differently.

To understand the situation thoroughly, and to connect to the experiences of the people involved you must throw yourself into the work processes. To investigate. To understand.

Which motivation fits with this? In any case, not by disqualification of the current situation. Then you do injustice to the people and you distort a clear view on the system.

"If you do not love what you are trying to change, do something else"