I was asked a question by a Twitter follower over the weekend:
“What are the pros & cons of using direct observations in hospital environment to identify value & non value adding activities?”
 It's a short question, but I didn't think I could answer it in 140 characters. So here goes (and please add your thoughts in the comments section).
@MarkGraban What are the pros & cons of using direct observations in hospital environment to identify value & none value adding activities
— Shana T (@Ten_Shana) February 2, 2014
There are many advantages of “going to the gemba” to observe (gemba being a Japanese word that means “the actual place” or, basically, the place where work is done).
As I wrote, in part, in my book Lean Hospitals:
How Do We Find Waste? Go and See
Once we know the definitions of waste, we have to take action. We have to “go and see” (genchi genbutsu, in Japanese), as Toyota would tell us. Ohno was famous for training engineers and managers to look for waste by drawing what came to be known as an “Ohno circle” on the floor, with chalk. The trainee was told to stand in the circle (just a few feet in diameter) and watch the process for hours, looking for waste. That is an extreme method and not one that is commonly used, but there are lessons to be drawn from it. First, you have to go and see with your own eyes, as meeting in a conference room to discuss the process is not as effective. Leaders at all levels have to go to the gemba to see what really happens.
In any organization, including hospitals, there are three forms of any process:
1. What the process really is
2. What we think the process is
3. What the process should be
Leaders cannot rely exclusively on reports, data, or metrics, especially early in the Lean journey. You might ask, “How long are patients waiting in the ED before seeing a doctor?” The hospital might already have measures and reports in place, but the most effective way to actually improve the process is to go and see for yourself to identify waste. This takes time, but that time will prove to be an extremely good investment for you and your team.
Some of the advantages of going to the workplace include:
- Seeing REALITY rather than relying on what people say about their work
- Building trust with employees, as they see that you see the problems they are facing (and are not blaming them for the waste)
- The opportunity to get staff feedback and patient feedback about what could or should be done better
- Making sure the definition of “value” is aligned to customer / patient needs
Some of the disadvantages of observing in the workplace might include:
- If there's not trust, employees might feel “watched” or “policed”
- In circumstances like that, employees might not do their work as they normally would (they might be nervous and make mistakes or they might do everything exactly by the letter of the process, when they might normally be more casual about their work)
- It might be awkward or uncomfortable to observe when patients are present
- When you observe you might see a limited snapshot of time (hearing things like “it's normally way busier than this” might tip you off)
All of those “con's” or disadvantages can be addressed.
If trust does not exist, then managers should first spend time in the gemba building relationships and talking with staff. Orient the discussion around “how can I help you?” instead of seeming judgmental about waste. Even if you're not being judgmental, pointing out the waste (and thinking of it as a systems/processes issue) might still lead to staff blaming themselves and therefore feeling criticized.
If we're going to be observing when patients are present, we can go out of our way to introduce ourselves to patients and let them understand why the observation (and improvement work) is taking place. You might have a patient say something funny, as happened to me and a team once. You can hang signs that inform people who enter the department that workplace observation is taking place (with the goals including quality improvement, waiting time reduction, etc.). Most patients are happy to see this happening, trust me.
You might decide to stay out of the exam room, leaving that to be a private moment between the patient and clinicians. There's so much waste in healthcare, we're generally not trying to start out by making the clinical encounter more efficient. We're looking for ways to prevent delays so the patient can get to the room more quickly, for example.
The way to address the “limited snapshot” problem is to observe at different times of the day and week… I always recommend to keep observing until you don't see anything really new. There will be diminishing returns to the observation and “how long you should observe” and “how many times you should observe” depends on the situation and circumstances.
As I talk about in the book, we can observe with one of two different lenses:
- “Activity of the Patient” (or “Product,” more generally like a tube of blood)”
- “Activity of the Operator” (the people doing the work)
Some other thoughts from Chapter 4 of my book:
Observers should strive to build rapport with the employee and allow the employee to concentrate on performing high-quality work. If the observer sees an error or mistake being made that would impact a patient, the observer has a responsibility to help the employee (and patient) by saying something about the error. Employees who have done the actual work should conduct activity of the employee observations, making it a peer-to-peer interaction. If outsiders or supervisors do the observation, employees might be more nervous about negative outcomes, or clinicians might be understandably upset if engineering interns are timing how long they are in the restroom. Staff members at any level deserve to be involved as a partner in this observation and improvement – to be a scientist, not merely a subject.
Additionally, having coworkers observe work will lead to more accurate analysis and identification of waste. They are also more likely to know when observed employees are using methods that are inconsistent with others or standard practices. This realization serves as the first step in determining what the best work method should be. The observation and analysis can also uncover activities that certain roles should not be doing.
Staff members at any level deserve to be involved as a partner in this observation and improvement - to be a scientist, not merely a subject. Share on XI think it's a key point to have coworkers do observation. It can't be just managers or consultants, for a number of reasons.
What are some of your tips and lessons learned?
What do you think? Please scroll down (or click) to post a comment. Or please share the post with your thoughts on LinkedIn – and follow me or connect with me there.
Did you like this post? Make sure you don't miss a post or podcast — Subscribe to get notified about posts via email daily or weekly.
Check out my latest book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation:
I don’t carry a clipboard, iPad, or anything else in my hands. If you’re standing there visibly taking notes it makes people nervous or perform in ways that they wouldn’t normally perform (as you discuss above). I use to retreat to an office and hastily jot down as much as I could remember (a shortcoming of this approach is potentially lost data), but now I use Siri and Notability to write my first draft notes. Seems to work pretty well.
I’m looking forward to reading others’ tips.
Great point… things like clipboards and especially stopwatches can be intimidating. We don’t want to be like the class “time study man” who annoyingly hovers over a worker like this old picture:
There’s an art to positioning yourself during observation — not right on top of people and not too far away. Staying out of the way is an important skill, because you’ll quickly annoy somebody if you’re constantly in their way.
For me works the following:
1. Study and deeply comprehend the process that i will measure, know the steps of the actual process, so i just have to take with me a simple matrix of the name of the step and a space for the time of the process and notes.
2. Use the clocks that are in the room, almost all the rooms have a clock, so i just put the hour when process started, back in my office I do the math about the time each process took, doing this I can focus in what is happening and not in the start/stop button.
3. Let know the staff and supervisor the intention of the time taking, while taking time I can see if the policies and procedures are being followed or not, but the feedback after the time taking should only be about the time. If I see something out of place an other meeting and approach should take place (of course, if it’s not harming the patient).
Greetings!
Great points, Karina.
I try to start with qualitative observation (identifying problems, doing spaghetti diagrams, etc.) before even talking about time (or measuring it).
It’s really important to emphasize with staff that we’re looking at the process, not looking to find fault with individuals.
Of course, if there’s no trust in the organization, that won’t be believed.
Another question is if you jump in and interfere or correct somebody when they’re not following the process. I think there’s an ethical obligation for a nurse who is observing another nurse to point out a problem that might harm a patient. Otherwise, I think you have to try to observe without constantly commenting or interfering.
You can always give feedback after the fact if it wasn’t a matter of patient safety or staff safety.
You can always ask the people working in the process for their feedback or ideas for improvement when they have a break or time to talk.