Book Review: Perfecting Patient Journeys

Healthcare is undergoing many changes these days which has long been overdue for those of us who have been patients.  Lean thinking has been spreading globally for decades in product and service businesses. In the last few years this value stream improvement methodology has been gaining support in health care.  Now there is a step by step guide for visualizing the patient experience and improving the flow of value with Perfecting Patient Journeys.

Published by the Lean Enterprise Institute (LEI) Perfecting Patient Journeys is a guide for leaders of healthcare organizations who want to implement lean thinking. Readers will learn how to identify and select a problem, define a project scope, and create a shared understanding of what's occurring in the value stream. Readers will also learn to develop a shared vision of an improved future, and how to work together to make that vision a reality.

The authors describe and advocate a value-stream approach to improvement bringing together both scientific and cultural components needed to transform Lean Healthcare.

The workbook comprises of 8 chapters which constitutes the steps of the improvement cycle:

• Team-based problem solving and learning for continuous improvement
• Scoping your improvement project
• Value-stream mapping – current state
• Future-state mapping
• Measuring the future state and planning for change
• Establishing project management
• Keeping your improvement project on track
• Moving forward- from projects and events to consistent practice

                            

The basis of the workbook was a field guide developed for support of training during collaborative sessions in a project with MHA Keystone Center for Patient Safety & Quality. Throughout the book the authors, who worked on the project, utilize their case study of St. Luke’s Hospital initiative to improve the performance of their emergency department as an example.  They include details of improvement from St. Luke’s that makes it easy to follow and implement this improvement approach.

While this workbook is intended for practitioners with direct interaction with patients it also helps senior leadership understand and support system level improvements. Written is a clear manner without excessive Lean jargon or terminology, this book presents the value-stream improvement approach, which simultaneously blends the ability to change structure and process while changing culture.

Perfecting Patient Journeys follows the style as other LEI workbooks but has a different look. This workbook doesn’t have the typical spiral binding of the other workbooks as it a hard cover book. Likely this was done to better market the target audience of healthcare professionals. Personally I prefer the spiral bound style for its convenience in the gemba or at team meetings.   

While the audience for this book is clearly healthcare workers it has easy application for any service process. This guide presents a method to sort through problems, establish priorities, and focus on solving the right problems with teamwork which is applicable in all processes. Lean practitioners and those alike interested in learning an improvement methodology based on eliminating waste within a value stream with teamwork will find this book a helpful reference guide.

Disclosure: My friends at LEI sent me a copy of Perfecting Patient Journeys for my review.

The Benefits and Impact of Global Quality Award Programs

In this month’s ASQ post by Paul Borawski he asks the Influential Voices to discuss the impact of Global Quality Programs.

Do you live in a country with a national quality program?  Is it serving to create role models for others to emulate?  Is the national program growing in visibility and perceived value and creating capacity for national excellence?

If you search Google for “Quality Award Programs” you may be surprised by the number of programs.  I certainly didn’t realize how many programs focus on quality. I suppose this speaks well for the emphasis on quality products and services.

I think we can all agree that a Quality Award for the sake of an award is not beneficial.

However, many organizations around the world are turning to quality award programs for more than just the recognition such programs offered. Companies realize that the awards also offer models and tools for implementing a quality strategy, benchmarking best practices, performing self-assessments and, ultimately, achieving improvements.

Many organizations are effectively using quality award programs to advance their journey to attain quality leadership. Here are some guidelines for effectively using quality award programs:

1. Do it to drive excellence, not to win the award.

Many organizations have gotten off track by making the award the ultimate goal. This can result in gaming the system to look better than you actually are. In the meantime, the organizations lose sight of their true purpose of providing value adding products and services to customers.

2. Use a long term focus.

Once and done is almost always a wasted effort. It is not enough to reach award winning levels of quality leadership. The real goal is to sustain quality leadership performance. Most quality award winning organizations will self-assess and apply multiple times over several years. They recognize that achieving and sustaining quality leadership is a journey.

3. Use the feedback.

It is always amazing when an organization goes all the way through the process of compiling and submitting an application and then ignores the feedback they receive from the evaluation process. This is the gold nugget. This can be some of the best advice an organization will ever receive from a team of industry leading experts. Smart organizations use this feedback as a major component of strategic and business planning to identify areas of focus.

4. Focus on process.

The results will follow. Most quality award criteria seek information related to business processes and business results. The key to success is to understand how processes drive results and focus on improving the processes so better results can be attained.

5. Develop internal expertise.

The awards cycle will provide valuable feedback to the organization, but it can take a long time to get the information. Organizations which develop internal expertise can strengthen their own assessment processes. This enables the organization to get regular and timely information for improving processes and performance

Quality awards are not indicators of previous or future performance. They are a one-time snap shot. If your organization is seeking quality improvement, then a Quality Award can play a significant part in helping you along the journey. Quality awards provide an excellent source for monitoring progress and identifying opportunities for improvement.

I’m part of the ASQ Influential Voices program. While I receive an honorarium from ASQ for my commitment, the thoughts and opinions expressed on my blog are my own. 


      

Six Suggestions to Allay People's Fear of Change

A reader asked me for some suggestions on relieving fear of change:

I am curious what you would recommend to allay people’s fears when for instance a physical change is taking place on the floor. An explanation is made, they are involved to a degree but ultimately it is for the good of the operation. This creates anger and I am at a loss as to how to diffuse this.

People commonly resist change for a variety of reasons.  Although you intend for the change to result in a positive outcome, change is often viewed as negative.  Before you can overcome the resistance it is wise to be aware of why the resistance exists. Usually it is a result of one of the following causes…

• People not agreeing with or understanding the value / benefits of the innovation.
• Fear of the unknown.
• People have had no opportunity to provide input in the planning or implementation of the change.
• Little or no reward / benefits to the people impacted by the idea.
• Increased effort from people required as a result of implementing the idea.
• Fear that the change will result in job cuts.
• Personality clashes between the people affected by the idea and the ideas inventor.
• No trust of the people who have been mandated to implement the change
• Belief that the change is unnecessary or will make the situation worse
• A belief that the idea is inferior to another idea.
• A feeling that the change will result in a loss of security, status, money or friends.
• Bad experiences from similar changes that had been or been attempted to be implemented in the past.

Being aware of the causes mentioned above and being able to specifically identify which ones may be relevant to our particular business greatly increases your chances of overcoming the resistance to change.

For your plan to be accepted, you must anticipate and overcome any negativity, anxiety and/or resistance. Here are a few suggestions that come to mind to reduce resistance to change:

Suggestion 1: Empower employees to become part of the change.  There are several reasons people resist change, one of which is fear.  Many people play "Gee, what if" scenarios over and over when a new idea is proposed.  When you begin to implement your plan of action, it's essential that you invite those around you to identify how the change will influence them, benefit them, and improve their present situations.

Suggestion 2: Keep your employees informed.  Communicate as much as you know about what is happening as a result of the change.  One of the major reasons people resist change is fear of the unknown.  If you communicate with employees and keep them informed, you put this fear to rest.

Suggestion 3: Break the change down into digestible chunks.  If it makes it easier for employees, introduce the change gradually.  You can give employees encouragement and help them focus on small steps they can take to move toward the future.  Celebrate their small successes.

Suggestion 4: Answer the "What's in it for Me?" question.  This suggestion is similar to Suggestion 1.  Generally people will accept change when they see a personal benefit.  Employees who are involved in determining the benefits of change are less likely to resist it.  Assist employees in identifying what the change will do for them.

Suggestion 5: Give employees some control over change.  As employees begin to focus on the benefits of the desired change, provide them with the opportunity to control the steps to the change.  Participants in change workshops have revealed that having control reduces the anxiety and stress associated with the change implementation and increases their motivation to make the change.

Suggestion 6: Help employees assimilate the change.  Once employees begin to experience change, help them assimilate it by reinforcing the personal benefits they're gaining

Change should be ongoing and employees should be a critical part of that process so there is not fear of change but a willingness to embrace it because it’s a part of the everyday process in the organization. As employees begin to demonstrate a willingness to assimilate change into their daily routine, they develop a commitment to the change, a willingness to stick to the plan of action.  The change actually becomes integrated into the work environment, and employees begin to feel a sense of satisfaction in accomplishment.  They readily see the payoffs associated with the change.  They enjoy, and may even take credit for, their participation in the process.  Employees can view their efforts to bring about change with personal respect and pride. The change becomes a part of their routine, and any lingering concerns vanish.

Lean Quote: Lean Improvement is a Better Option in a Competitive World

On Fridays I will post a Lean related Quote. Throughout our lifetimes many people touch our lives and leave us with words of wisdom. These can both be a source of new learning and also a point to pause and reflect upon lessons we have learned. Within Lean active learning is an important aspect on this journey because without learning we can not improve.

"A competitive world has two possibilities for you. You can lose. Or, if you want to win, you can change." — Lester Thurow, Dean, Sloan School of Management, M.I.T.

In recent years, more companies have adopted Lean as a continuous improvement method to improve profitability, enhance customer satisfaction and maintain a competitive edge in the marketplace. Based on a customer-focused view, Lean can provide a strong foundation for any organization that wants to incorporate continuous improvement into its operating philosophy.

Starting the Lean journey can be difficult. It is critical to have alignment and clearly state the need for improvement from the beginning. There are ten key steps that should be taken when starting the journey towards a Lean improvement.

1. Establish a need to improve and obtain management commitment

2. Define the improvement objective

3. Identify and acquire necessary resources

4. Collect information and determine current state

5. Uncover the root cause

6. Identify and test countermeasures that will meet the improvement objectives

7. Develop plans for implementing the countermeasures which ensure buy-in

8. Implement the improvement

9. Standardize the improvement

10. Repeat starting a step 1

Every system should have provision for an improvement cycle. Therefore when an objective has been achieved, work should commence on identifying better ways of doing it. There is no improvement without measurement. An organization must establish current performance before embarking on any improvement. If it does not, it will have no baseline from which to determine if its efforts have yielded any improvement.

Lean improvement is about the entire organization and everything it does. Lean Thinking has to be a prime concern of executive management and its success depends upon commitment from them. Their commitment must also be highly visible. It is not enough to demand improvement. If executive management does not demonstrate its commitment by doing what it says it will do they cannot expect others to be committed either.

Lean manufacturing practices, which are at the very core of change, are an absolute necessity in today’s competitive global marketplace. While the pursuit of Lean is not a destination but a journey it is clear that organizations that stretch themselves to build a culture around these values will ultimately have a big advantage those who do not.

 

The Lean Formula for Change

For virtually everyone change means hard work, risk, and the need to learn new ways for unproven benefits. Change is one of the most difficult things for humans to readily accept. Charles Darwin said, “It is not the strongest species that survive, nor the most intelligent, but the ones who are most responsive to change” which holds true for culture change.

Fortunately, there is a formula that provides insight into how to successfully facilitate change:

L x V x K x AP x A > R = Change

Where:

L = Lever: Find a sense of urgency by identifying a crisis in which action is the only choice. It is necessary to overcome inertia.

V = Vision: How you would like things to be in the future, this is the “True North” thinking.

K = Knowledge: Learn the skills necessary to facilitate the change. Find a change agent. Understand and disseminate the lean knowledge.

AP = Action Plan: Actions and strategies needed to move the organization toward the vision. It is important to begin as soon as possible with visible activity. Often, a great start is to identify and map your value streams.

A = Alignment: Communicate the why and how of the vision to inspire people to want to try to achieve it. As you gain momentum you need to expand your scope. Apply strategy deployment (Hoshin Kanri) to facilitate horizontal and vertical alignment.

R = Resistance: People tend to naturally resist change. Reduce resistance by making the change known, easy, beneficial, and popular.

To ensure successful change all of these elements are needed. If an element is missing you won’t get change but rather something short of that as shown below:

Lever x Vision x Knowledge x Action Plan x Alignment = Change
               Vision x Knowledge x Action Plan x Alignment = Status Quo
Lever x                 Knowledge x Action Plan x Alignment = Confusion
Lever x Vision x                          Action Plan x Alignment = Frustration
Lever x Vision x Knowledge x                          Alignment = False Starts
Lever x Vision x Knowledge x Action Plan                        = Resistance

There is no quick solution for creating a lean culture. Successful initial implementation and ongoing maintenance of process improvements, among other things, requires overcoming the resistance to change.

Collaboration Techniques for Moving Ideas & Decisions Forward

Collaboration and teamwork make an important contribution to the success of business initiatives like quality improvement, product development or customer service. To create effective teamwork across your organization, you need to break down any departmental barriers to collaboration so that you can draw on the best people. You need to set clear objectives and define working relationships so that members can work as a cohesive team, and you must provide tools that support efficient collaboration.

Team collaboration and decision-making works best when everyone is involved in the process, from brainstorming ideas to implementing the decision. Here are some tips for moving decisions forward in a team-meeting environment.

1. Keep the group small; five to nine members is optimal.

2. Announce the meeting(s) in advance. Define the issues to be discussed and invite attendees to arrive prepared with ideas and possible solutions. (On the whole, individuals are better at suggesting ideas, while groups are better at evaluating them.)

3. Use a “round robin” format to collect ideas. Go around the table and ask people to each mention the ideas or solutions they’ve developed. List on a screen, flipchart or white board. (This format is used to gather information and does not allow criticism or evaluation.)

4. Encourage people to discuss the idea with the group, not with the originator. Once the idea is on the table, it’s a group issue, which is discussed by the whole group.

5. Rephrase criticism in a positive way. Rather than saying, “We did that and it failed;” try “What could we do differently this time to make that solution work?” or “Have our circumstances changed so that the solutions could work now?”

6. Ask for positive remarks from negative people. If a lot of negative comments are made, list them on a flipchart in one column (con). Create a positive column (pro) next to the con column, and ask the people who made negative comments to suggest a positive comment. This approach reduces defensiveness, broadens thinking, and encourages people to look for solutions rather than focus on the problems.

7. Set an example by not defending your idea. Let other team members defend it. Remind the team that this is a group issue. If necessary, clarify or explain your idea in more detail, but don’t defend it. People will tend to follow the example you set.

Collaboration and team work create an environment that allows the collective knowledge, resources and skills of each team member to flourish. When people work together they can complete tasks faster by dividing the work to people of different abilities and knowledge. Teamwork can lead to better decisions, products, or services.

Both Attitude and Behavior Change Are Key to Success

Attitude and behavior are closely related in some sense though they are two different concepts. One of the most important differences between behavior and attitude is that attitude is internal whereas behavior is external in sense. In other words it can be said that behavior can very well be seen by others as it is external whereas attitude is shelled within the mind of the individual and hence cannot be seen by others immediately.

Several situations within the office affect attitude and behavior. For an employee to consistently display good behavior in the workplace, he must maintain a positive attitude towards his job. If your employee develops a dislike for his job, he might lose interest in his assignments or lack motivation. These negative feelings influence his behaviors and might trigger low productivity. In addition, an employee's negative attitude can become evident with other actions, such as poor performance, regularly staying away from work, poor business ethics and perhaps favoring one supervisor over another. To the contrary, employees who feel respected by you and other coworkers, and those who maintain a good attitude, typically respond differently and exhibit appropriate behavior in the workplace.

Leadership behavior plays a very important role in enhancing employee job satisfaction, work motivation and work performance. The major type of supervisory behavior that has been identified as influencing work motivation and performance include positive achievement behavior and the behavior that is expected to lead to dissatisfaction include authoritarian or arbitrary and punitive behavior

We tend to assume that people behave in accordance with their attitudes. However, social psychologists have found that attitudes and actual behavior are not always perfectly aligned. In some cases, people may actually alter their attitudes in order to better align them with their behavior.

Behaviors are much easier to change than attitudes. When we focus on attitudes, we are setting ourselves and our employees up for failure because even if they sincerely want to change, they don’t have anything tangible to work on. Once we’ve clarified the behaviors that we want to eliminate or see more of, it is relatively easy to set performance expectations, and measurement becomes a matter of whether the behavior did or did not happen.

Some managers I’ve worked with don’t want to move past attitudes to focus on behaviors. They will argue that if the employee doesn’t have the “right” attitude, then they can’t be successful. While attitudes can have a powerful effect on behavior, they are not set in stone. The same influences that lead to attitude formation can also create attitude change.

In order to have meaningful change we have to change both attitude and behavior together. Change in thinking will lead to behavioral change. Alternatively, change in actions will eventually lead to changes in attitude. This combined approach provides the most success by providing positive thinking with the right methodology to implement and sustain change.