Here's a thought starter for a Monday morning – I'm looking forward to hearing your perspectives. A few weeks ago, I heard a leader from a healthcare organization (one that will remain unnamed) say this:
“In healthcare, we get results from people's exceptional efforts in the face of imperfect circumstances.”
The exact sentence is paraphrased but these four words are exactly what was said: exceptional efforts… imperfect circumstances.
I've heard that said before… but what struck was the sense of pride behind the sentence in this case.
Healthcare is full of heroes. That word applies on a few levels. There's the inarguable heroism of somebody who can save a child's life when their heart has stopped beating or when they have cancer. That's nothing but goodness. We should all be thankful that medical professionals have the skill and drive to make that happen.
The other kind of heroism isn't always helpful – in the long term. This form of heroic activity is often chalked up as “fire fighting.” It's a mixed bag – in the moment, the “exceptional efforts” are very necessary in light of “imperfect circumstances.”
I'm reading the book by Peter Pronovost, MD, called Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out, and there are many examples of both the fire fighting and the imperfect systems.
Let's say a physician is about to insert a central line catheter into a patient. This is a risky proposition since there are, on average, 2 infections per “1000 line-days” and up to 25% of these infections are fatal. As Pronovost's work on checklists showed, a simple set of tasks can virtually eliminate these infections. They are “largely preventable,” Pronovost says.
Pronovost cites these stats in his book:
…infections from central line catheters is four infections per thousand catheter days (a catheter day is one day that one patient has a catheter). That means each year roughly eighty thousand patients become infected as a result of placing central lines, and thirty thousand to sixty thousand die, at a cost of up to $3 billion nationally.
But if there's a proverbial fire — let's say that one of the basic central line supplies is missing, like one of the drapes. A nurse might be a hero — go through an “exceptional effort” to race down to another unit to get that drape. That might delay the doctor, meaning other patients have their care delayed. The “imperfect circumstance” is that there's not a good system to make sure everything is stocked properly — materials are found where they're needed in the right quantity 100% of the time (that would be the Lean goal).
Pronovost confirms what we see from a Lean perspective, that these “imperfect circumstances” are common:
Furthermore, the way this work is organized, or in many cases not organized, often prevents patients from receiving the care they should; supplies are not stocked, labeling is ambiguous, communication is vague, absent, or confusing, and critical equipment is sometimes simply just not available, even at America's best hospitals.
The problem with being a hero is that there's another fire to put out. It's easy to rationalize putting out other fires — after all, you're helping in the short-term. People are under time pressures, so they move on — put the fire out (exceptional effort over) and they don't stop to address the systemic imperfect circumstance. “We don't have time to fix the system,” is a common lament. Many organizations seem to accept “lack of time” as an excuse instead of a problem that can be solved. The Lean approach would ask “why isn't there time?” and “what can we do to create time by eliminating waste?”
Lean thinking is powerful in that a Lean organization finds the resources and the time to put out the fire and THEN finds time to fix the system. It might be the natural work team that does this (an ideal state, people who do the work fix the work) or it might be a Lean project led by a specialist resource (or even a Six Sigma project).
Being a hero is fine if you're not constantly putting out the same fire every day. To really improve quality and ensure consistently good care, we need to fix the system. In the above example, when the system isn't fixed, the physician might be tempted to cut a corner the next time and insert the central line without the proper draping (yes, it's conceivable that would happen. A patient might get an infection because the full checklist wasn't followed.This is a systems failure, not solely the fault of a “bad doctor” who made a bad decision – life's not that simple (and this is a theme in Pronovost's book, that we have to move beyond blame to look at underlying systems that create these bad situations).
Pronovost writes about the rational decisions people make to, under time pressure, NOT be a hero (although they ideally would):
Time she spends looking for the antiseptic is time not spent with her patients.
Without fixing the system, the “exceptional effort” that helps Patient A might be a detriment to Patient B, Patient C, Patient D, Patient E, and maybe Patient F.
The very same drive and ability to constantly be a hero might be just the thing that holds back improvement of the overall system. So while the person I referenced at the start of the post spoke with pride about the “exceptional efforts,” a Lean thinker would typically say that exact same sentence with a bit of remorse that the “imperfect circumstances” are so easily tolerated. Exceptional efforts are good. Eliminating imperfect circumstances is better.
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Spot on Mark! In my world we have a saying, “As the captain, you use your superior judgment to avoid the need to use your superior flying skills.” It’s our way of saying “Eliminate imperfect circumstances.”
Heroism is, optimally, rare. Put another way, when I get home from a trip and my kids ask how the trip was, I respond, “Nice and boring.”
Thanks, Monty. I received an email from a friend, in response to this post, that I can’t post here. But the gist of it, in manufacturing, was about the heroes having to work Easter Sunday to hit an arbitrary management target… with no discussion about how to fix the system to avoid working on any Sunday.
Mark, your blog coincides with my experience and with a useful presentation I attended while at the ACHE Congress in late March. The topic was “Best Practices of High-Reliability Hospitals”. The outline of the presentation was based largely on the work of Weick and Sutcliffe as outlined in their book, “Managing the Unexpected”. I found this framework to be useful. 5 attributes (based on mindfulness):
1 preoccupation with failure
2 commitment to resilience
3 deference to expertise
4 reluctance to simplify
5 sensitivity to operations
“Mindful Management” means: 1) noticing the unexpected in the making and halt its development, 2) if it can’t be halted, focus on containing it, 3) if it can’t be contained, focus on resilience and swift restoration of system functioning.
The presenter described the 5 attributes in more detail, and I won’t elaborate here. Suffice it to say, I think there is something here which supports and incorporates lean thinking and would be beneficial to learn and apply in healthcare.
The focus was on creating reliable systems, not on continued individual heroism.
.-= Mike Stoecklein ´s last blog ..More Thoughts on Innovation =-.
Thanks, Mike. The “preoccupation with failure” is a strong theme in the book “Why Hospitals Should Fly” by John Nance (lessons from aviation safety for healthcare).
I’d be interested to learn more. Does “swift restoration of system functioning” mean fixing the underlying system, not just putting the fire out?
Excellent post, Mark. I am interested in people’s experience in taking the next step: tangible actions to address these perceptions (some may call them mental blocks or mindsets). You hint at an approach with your comment, “the ‘exceptional effort’ that helps Patient A might be a detriment to Patient B, Patient C, Patient D, Patient E, and maybe Patient F.” Another angle: constant firefighting breeds burn-out and resentment.
Perhaps the most troubling part of your post was the beginning, the fact that it is a leader of the organization that expresses pride in the exceptional efforts, rather than setting a higher standard while acknowledging the current need for such actions. I guess this suggests the best place to start to change those perceptions!
Dale
The book “THE LEAN MANAGER” (Balle/Balle) discusses the ‘SHRUG FACTOR’ as meaning people who shrug off problems and think “that is just how things are around here”. The authors say no lean tools will help those with the shrug factor. The hospital exec quote seems like a shrug to me.
Culturally, organizations need to learn there is no reason to shrug because Lean thinking and tools can help transform the current state. Knowing change is possible instead of acquiescing to the difficult current conditions is the first step.
.-= Brian Buck ´s last blog ..Lean Related Posts Roundup =-.
Mark, per your question “Does “swift restoration of system functioning” mean fixing the underlying system, not just putting the fire out?”, I think the answer is “yes”. Here’s a more detailed breakdown on the Weick & Sutcliffe model. This might make for a nice podcast interview (one or both of the authors)
1 Preoccupation with failure.
– focus on predicting and eliminating catastrophes, rather than reacting to them
– constantly thinking about something that they may have missed that place patients at risk
– near misses are viewed as opportunities to improve current systems not a validation that the system’s defenses worked
– use attention to near misses to avoid complacency and increase reliability
2 Commitment to resilience
– maintain the ability to quickly contain errors
– learn to improvise when an anomaly occurs
– assume that the system may fail in unanticipated ways (despite multiple safeguards and defenses)
– train staff to: perform quick situational assessments, work effectively in teams, defer decisions to those with relevant expertise, practice responses to systems failures
3 Deference to expertise
– culture where leaders defer to persons with the most knowledge relevant to the issue and with the information most critical to a crisis
– all staff comfortable sharing information and concerns with others
– patient or family may have information that is important
– staff are commended when they share concerns
– de-emphasis on hierarchy
4 Reluctance to simplify
– recognize that organization is complex and adaptive system
– accept the work as complex
– don’t accept simplistic solutions
– but, work to make processes as simple as possible
– staff trained to recognize range of things that might go wrong
– don’t assume a failure has a single cause
– experienced team members with expertise continually refine methods and processes
– avoid oversimplifying the explanation of how things work so that we can develop a comprehensive understanding of all the ways in which a system might fail
5 Sensitivity to operations
– mindful of the complexity of the system in which they work
– maintain situational awareness to quickly identify and address anomalies and potential errors
– pay attention to broad range of factors (potential distractions, length of time on duty, availability of needed supplies)
.-= Mike Stoecklein ´s last blog ..More Thoughts on Innovation =-.
Definitely thought provoking, Mark. Thanks.
From the celebration perspective, what occurs to me is the realization that taking care of people always seems to involve decision-making under conditions of uncertainty and risk. The ‘uncertainty and risk’ part is what I think of as the ‘imperfect circumstances’ – always there, even in consciously-designed and improved systems. The exceptional/heroic part would be the remarkable way trained and experienced practitioners can reach through the smoke and confusion and come to the right assessment and then next best action to take.
Now from the ‘lamented’ perspective, watching with the mind’s eye the heroic practitioner/manager expending energy and resources compensating for deficiencies of the system or individuals in it – that really is regrettable. The good news is that we can do something about it using Lean thinking and tools.
I love your illustration of Pronovost’s work with central-line infections. His collaborative results with Michigan ICU’s has shown us all that ‘zero-defect’ care is a live possibility. Instead of thinking of complications (infections) as an inevitable part of the natural order of things, we can now consider what would it take to eliminate them completely.
I’ve wondered if people could be trained when they notice they are ‘firefighting’ to make sure at the end of the procedure that they consciously debrief with each other the insights/opportunities for improvement and capture them for the next staff meeting where a redesign or upgrade could occur. Hmmm!
/Dr. Pete
Mark,
I agree it is lamentable that people such as your anonymous healthcare leader find it heroic to support the insanity of continuing to “fight fires” with no effort to prevent recurrence. People that are stuck in this environment are simultaneously Firefighters and Arsonists, creating the fires by not taking the time to eliminate the cause of the fire when it happens (or shortly thereafter). When we diplomatically reveal their arsonist alter egos to these organizations, they sometimes start to see the light. I agree with Mr Buck’s comment that “there are no lean tools to help those with the shrug factor”. That’s because these people don’t need tools; they first need motivation to want the tools. Motivation to be a part of a continuous improvement culture. They also have to be given the ability and opportunity to see the waste around them every day and have a healthy dissatisfaction with the way things are. This change in mindset will only come if the leaders allow it, understand it and support it. They either are or they aren’t on a Lean/Six Sigma journey. And, as we say with so many important matters, the spirit of continous improvement has to begin with the leaders.
By the way, I know who your anonymous healthcare leader is; I have met him at numerous companies in different industries over the years.
.-= Brian Maready ´s last blog ..Strategy Deployment =-.