An American ED Doc in New Zealand – Reflections on Pushback and Learning

Mark's note: Today's guest post is from Dr. Mark Jaben, an American doctor who worked in New Zealand, leading to this blog post. I have talked with Mark about Lean quite a bit over the past few years and we were able to cross paths at Cindy Jimmerson's Lean Healthcare West conference in Montana last year.

In 2008 to 2009, I worked in New Zealand as an emergency physician and helped implement Lean concepts and practices at my hospital. During that time, we even received a visit from the then new Health Minister, Tony Ryall, who was interested to see what we had done. We were quite excited about the 6 hour rule, which mandated that the disposition of all ED patients should be achieved within six hours of arrival. In our small hospital, where we were already beating the 6 hour rule by a wide margin,  it meant we could completely shut down at lunch and tea and still easily get our work done! Of course, we never did this, but it does speak heaps (kiwi speak for ‘a lot') about performance measurements and incentives, a topic for another day.

Notwithstanding the warm spot in my soul for New Zealand, Dunedin Hospital's lean story has been of great interest because it portrays so well what so many around the world have experienced: enthusiastic beginnings, based on the inherent appeal in Lean concepts, tempered by the reality of formidable roadblocks. It reminds me that despite the beauty in the Lean philosophy, implementation takes hard work, attention to detail and persistently returning to the core concepts in the face of those obstacles. What are those concepts?

1. Gain agreement on the problem – to decide which of the many outstanding issues should be addressed next and to initiate consensus building by gathering everyone at the same starting point
2. Gain agreement on the parameters for success – to learn what each stakeholder needs from a solution to be successful in their own work
3. Only then, gain agreement on countermeasures to be tested – to learn the inevitable unintended consequences, and guarantee that any plan put in place actually performs as expected.

In 2008 (as Mark blogged about), Dunedin Hosptal launched their ‘Putting Our Patients First' project, looking to leverage the 6 hour rule to provide better care to their patients. By 2009 (new post), it had become clear that despite good strides toward improvement in the ED, accomplishing their goal of reducing ED wait times would only be achieved by the engagement of other departments in the hospital. ‘Lowering the stream' revealed a new set of stakeholders. Did they then pause to make sure they had gained the necessary agreements? Without these in place, it is tough to craft countermeasures that will work and be accepted. See this recent blog post with a 2010 update on the hospital's lean journey.

Pushback and reluctance to change are sure signs that either the underlying purpose was not agreed upon by all the stakeholders and/or at least one of these stakeholders is being asked to do something they really believe will hinder their own success. I am reminded of a story told by a hospital CEO, who led a kaizen event focusing on their outpatient lab ordering process. They gathered each and every person with an interest and redesigned the process from doctor's office to collections, projecting significantly reduced turnaround time and increased revenue, while reducing work hours and phone calls. The COO enthusiastically endorsed the new plan. Four months later nothing had happened. It turns out the revenue cycle manager sent her assistant to participate and didn't attend. She was concerned about the increased work this would force upon her small department and budget.

Pushback and reluctance to change do, nonetheless, indicate that people are engaged at some level, at least enough to have a contrary opinion (see Mark's recent post on this topic). This opening is an opportunity. Seeking agreement on the parameters of success surfaces assumptions and preconceived notions about what people believe they need to be successful in their responsibilities. These are often very deeply held, personal notions most people do not feel comfortable sharing. But people will eagerly tell you why somebody else's plan will not work. Then countermeasures can be crafted to test these objections, important learning that validates or refutes assumptions and preconceived notions, which enables people to move forward with valid and accepted ideas. Until then, it's tough to get progress.

The doc thinks the hospital needs a culture change

As Michael Balle has written:

‘Culture is defining success and the acceptable means to achieve it.'

Did they gain agreement on what these other departments would need to remain successful while still supporting the goals of ‘Putting Our Patients First'?

Certainly computer simulations can be helpful. Certainly backfilling positions is essential to maintain care while freeing time for people to work on improvement. What was done to gain agreement that those tactics were the proper ones to pursue? Is this the only way to learn what was needed? Aren't there other countermeasures that in the meantime could be tested that don't run the risk of efforts grinding to a halt, thereby maintaining the momentum while waiting for the necessary funding to materialize?

The nurses feel their work is still as bad as before

Did they translate the goal of ‘Putting our Patients First' to activities at the frontline aimed at seeing and solving problems that hinder people from meeting this measure? Is the Health Ministry's 6 hour rule treated as a performance measure, a punishment if not met, or as a learning measure, a guidepost to spur engagement and innovation.

Now the DHB wants to see results

Did they do enough up front to specify and gain agreement on the results required for success? It seems to me they got exactly the kind of results they should have wanted. Lean tools can certainly help solve issues, but their more important role is to surface problems so you can become aware of the obstacles you never realized, the very ones that could derail any effort. Their Lean initiatives in the ED enabled them to see the other hospital functions that would really be instrumental in putting their patients first. Tackling these should move them closer to their goal.

This highlights perhaps the most pernicious assumption of all, one that often derails improvement attempts: the fear of failure. Our medical training includes a ‘blame and shame' heritage that makes any failure unacceptable. Unfortunately, we have lumped our efforts to improve the process of care delivery in with our responsibility to provide the best patient care possible. The only way to truly learn how to improve is by experimenting and challenging what we do. Experimentation, however, assumes the experiment could fail. Without acknowledging this possibility, it is impossible to experiment. Of course, a failed experiment tells you what doesn't work, but even this moves you closer to learning what does. So, if learning what works better is the desired result, it is impossible to fail.

Performance measures displayed on the dashboard would provide a much deeper and richer understanding if always reported with an asterisk, the learning factor.

If a performance measure that hadn't changed was accompanied by an explanation of what countermeasures had been tried and shown not to have an affect, hasn't important learning still been achieved, and doesn't this result represent progress?

One of-the hardest things in medicine is what to do when care plans are not panning out as expected. We categorize a patient's problem and head down that path. Our brain doesn't easily challenge that initial assumption. It takes hard work, attention to detail and persistently returning to the core concepts to retrace our thought process, sometimes to the very beginning.

Lean tools provide the framework and discipline to keep us on track. Making sure that the infrastructure of agreements is in place (agreement on the problem and agreement on the parameters of success) refocuses efforts primarily on learning, rather than just results, thereby eliminating the fear of failure, and enabling the use of experimentation through continuous improvement to achieve those results.

A primary focus on learning, not results is, ironically, the path to those desired results.

Dr. Mark Jaben currently resides in North Carolina, where he is a board certified emergency physician with over 25 years in community practice.  After more than 20 years at one institution, he has spent the past 5 years doing locums work at more than a dozen hospitals, from small rural to large volume urban facilities, which has afforded him the great opportunity to experience both the unique challenges as well as common issues shared by health care institutions in the US and around the world.

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