I just read Dr. Atul Gawande's latest piece in the New Yorker: “Slow Ideas: Some innovations spread fast. How do you speed the ones that don't?”
There's a lot to think about and I hope you'd also see parallels to the spread of “Lean Management” and “Lean Healthcare” as “slow ideas.” How can we speed up the spread of good ideas?
Gawande compares two new medical technologies from the mid 19th century: anesthesia and antisepsis. Why did one new practice spread more quickly than the other?
When surgical anesthesia was invented and proven, it only took a few months to spread around the world (an in days before modern communication technology):
The idea spread like a contagion, traveling through letters, meetings, and periodicals. By mid-December, surgeons were administering ether to patients in Paris and London. By February, anesthesia had been used in almost all the capitals of Europe, and by June in most regions of the world. Read more
Whereas new methods for preventing sepsis and surgical infections, a much quieter problem than a patient screaming on a table, spread much more slowly, even though there were “strikingly lower rates of sepsis and death.”
Gawande explores different theories about why anesthesia would spread faster:
- Economic incentives were equally well aligned for both new methods (good for doctors financially)
- Both approaches violated prior beliefs and were simply hard to believe
- Both methods required technical complexity (neither was easy)
There are some interesting mental models exposed in the piece, including the idea that discharging pus from a surgical wound “was thought to be a necessary part of healing” and that surgeons wore “black frock coats stiffened with the blood and viscera of previous operations” as “the badge of a busy practice.”
Gawande posits this as the key difference between the acceptance of anesthesia versus antisepsis:
So what were the key differences? First, one combatted a visible and immediate problem (pain); the other combatted an invisible problem (germs) whose effects wouldn't be manifest until well after the operation. Second, although both made life better for patients, only one made life better for doctors. Anesthesia changed surgery from a brutal, time-pressured assault on a shrieking patient to a quiet, considered procedure. Listerism, by contrast, required the operator to work in a shower of carbolic acid. Even low dilutions burned the surgeons' hands. You can imagine why Lister's crusade might have been a tough sell.
This has been the pattern of many important but stalled ideas. They attack problems that are big but, to most people, invisible; and making them work can be tedious, if not outright painful. Read more
Does Lean Healthcare solve problems that are “big but, to most people, invisible?” Is the work required to become a Lean thinker and a Lean organization “tedious, if not outright painful”?
Although hospitals (and their employees and patients) are suffering from poor quality and patient safety problems, low morale, long waiting times, and financial difficulties, hospitals have a choice between doing more of the usual (such as merging, scaling back services, and laying off employees) or managing differently and reducing waste (through Lean).
Hospitals rarely get criticized for NOT trying a new approach to structuring and managing their organizations. They can point fingers and blame outside factors (like sequestration and the Affordable Care Act) and who criticizes them for being in a challenging industry?
Gawande writes about how healthcare is addicted to fancy new technological solutions. Lean management requires diligent analysis and disciplined daily practice. It might seem boring to some.
The article also explores the lack of adoption of good practices for childbirth and post-natal care. Even when proven “best practices” are simple and require no money or resources, they are often not adopted (yet hospitals spend money on new technology that might not be as effective).
Gawande explores three common methods for trying to get people to adopt a new process (think about this in terms of something detailed like hourly rounding or a higher level adoption of Lean methods):
- Saying “please do X” to people (“it works, but only up to a point”)
- The “law and order” approach of “you must do X” – this works, but people with rare skills will often just quit their jobs under threat of punished for something
- Offering incentives (the “kinder” approach to #2) – it's really hard and complicated to manage this
None of the three “achieve what we're really after: a system and a culture where X is what people do, day in and day out, even when no one is watching.” I agree that's what we're looking for.
We can say “please adopt Lean management.” I would be in favor of “mandating” it, since hospitals would probably do the bare minimum required to satisfy government regulators that they are “implementing Lean” and positive incentives could be gamed or fudged.
So how do we create change? Gawande suggests a few key approaches:
- You have to “understand existing norms and barriers to change,” understanding “what's getting in their way.” This requires a lot of one-on-one mentoring of people.
- “Evidence is not remotely enough,” as you need “seven touches” in talking with people seven times
- Having seven key, easy to remember messages or pitches about the idea
Gawande shares examples of changing norms around the world. He talks about people being given classroom training and then being visited on site “to observe as they try to apply the lessons.” That's coincidentally the same approach I take with my “Kaizen Kickoff” workshops – classroom time and one-on-one mentoring and coaching. Kaizen (the practice of continuous improvement) also seems like a classic “slow idea.” But, it's spreading.
As usual, Gawande's article is full of rich examples… there's a lot to chew on and to talk about. What other things stood out to you in the article? Read the full article.
You can also see Gawande's recent appearance on The Colbert Report:
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Lean spreads slowly despite pointing out visible and immediate problems and making life better for managers.
I see a different dynamic: Most top leaders are literally afraid of Lean because it easily and quickly proves them wrong, in a very public way. They want to avoid feeling threatened, embarrassed, vulnerable, incompetent, that they have lost control, or feeling they have failed.
Preserving their image of themselves is far more important than learning and participating in the spread of good ideas.
Is Lean “better” for managers in the short-term? It’s “more work” and requires learning something new, supervising differently…
It seems like the example of Lister’s antiseptic… it stings when you put it on your skin (some immediate pain) but with the promise that it will be better later on. People generally aren’t good at delaying gratification, it seems…
And that’s what makes it difficult, if not nearly impossible, to speed up the spread of Lean.
It’s not inherently a slow idea. However, like language or
music, it is a behavior that is hard to learn for mature adults. If
you start out in a company where lean management is the norm and
you are properly inducted in it, the process is no more painful or
lengthy than learning how to behave in any management system. The
definitions of “idea” as well as “lean management” are rather
loose. All things are ideas. Not all ideas are things. What people
mean by lean management varies a lot. Kaizen, as Masaaki Imai
pointed out and Dr. Robert Maurer demonstrated in his work in
psychology and brain science, helps people change by changing how
the brain is wired through repetition of very small experiences of
success. Slow or fast depends on how much rewiring needs to be done
and how frequently you practice.
What makes an idea “fast” or “slow” seems to be based on society’s response to an idea. I think 25-30 years of history shows that lean and kaizen are “slow.”
Bob and Jon, I liked your comments. Why would anyone in charge tolerate a maverick pointing out errors in the process?
There is only one reason not to give up on lean altogether. In his book, The Achieving Society, David McClelland theorized a society can only advance economically by telling stories of achievement to
its children. Lean is needed now to generate stories of achievement
to share with the next generation. Have to change the brain’s
wiring before it is too late.
As discussed above, Lean can be slow to implement because it may be incompatible with the organization’s management approach and the organization’s culture.
A perfect example is the leader that seemingly thrives on holding people accountable but in fact has developed an organization of bullies at the top end and drones in middle and at the front line.
How does this organization turn this around so that senior leaders are coaching and developing? Much time, which is available to all but desire for personal change is frequently not there. So while the attributes of Lean are desired and not readily cast aside, the tension rests with top leaders who must change or recalibrate what Lean means to them.
I think there’s an interesting and meaningful difference between “slow to implement” and “slow to spread.”
Adopting the use of anesthesia has to be considered relatively easy (hearing about it, seeing the benefit, accepting the idea, getting trained, doing it) compared to Lean. Anesthesia is a practice as opposed to a big holistic management system and philosophy, right?
I think Lean is sort of like EMR systems. They aren’t easy to implement, take many years, not everybody buys in (a Lean friend was recently at the hospital and saw the E.R. doc handwriting chart notes because it was easier than using the computer).
EMR spread was sped up by federal stimulus money and incentives. But, I think true and full EMR adoption and use is still a “slow” idea (what’s the benefit to doctors???).
But great point about Lean being incompatible with existing culture. As David Mann said (and I’m sure others) — Lean isn’t that complicated, it’s just very very different.
How do we create the desire for personal change? Dr. John Toussaint talks about his own personal change – I guess the incentive and drive came partly from his board members…
“How do we create the desire for personal change?”
The benefits of embracing lean for the individual must exceed the costs of embracing lean. The costs are substantial for the early adopters:
“Most top leaders are literally afraid of Lean because it easily and quickly proves them wrong, in a very public way. They want to avoid feeling threatened, embarrassed, vulnerable, incompetent, that they have lost control, or feeling they have failed.”
I have been searching for the answer for a long, long time. Luckily, my favorite team is a couple of bird dogs. My dogs’ performance was spectacular. My performance brought the team down. When my performance hit rock bottom, my lean skills kicked in. I improved the process of learning how to shoot a shotgun. My shotgun target can be seen at http://www.jfshooting.com
Lean skills are inventing skills. After you become proficient at improving your company’s products/processes, start improving products/processes that you use off the job. Until all companies embrace lean, the opportunities for improvement are endless.
This story is not unique. I imagine every individual with a US patent has been innovative on the job. Instead of wasting your money on a lottery ticket, make an improvement at work. Odds are better with lean.
I don’t think people with patents are the only creative people at work. I think everybody has some creativity that might have been beaten down by decades in a bad system, but they have it.
Kaizen – everybody, everywhere.
I never said people with patents are the only creative people at work.
No, but many people think that, unfortunately.
I think it would be interesting to ask the various Lean
healthcare CEOs why they want to be Lean. To work lots of projects
To save money To differentiate our hospital from the competition To
save our hospital To engage employees To make healthcare safer To
make me a better leader I think depending on the answer, you can
estimate how quickly Lean will spread. In my own organization, our
CEO wanted Lean because he or she saw Lean as a better way to tell
(make) people do what he or she wanted them to do. The last thing
our CEO wanted to do was change his or her leadership abilities.
After a good Lean start, the transformation has ground to a halt
due to the CEO’s inability to change.
Here is Dan Markovitz’s take from his blog:
How to make lean ideas spread more quickly
[…] It’s not just the AMA… but it’s commonly said that it takes 15 to 20 years for a new practice to be widely accepted as a “best practice” throughout healthcare. It’s a cautious, slow moving industry, I guess (see my post about Atul Gawande’s excellent article on “fast ideas and slow ideas.”) […]
[…] box_size=”630″] According to leanblog.org, Dr. Atul Gawande an Indian American surgeon and journalist suggests the following steps towards […]