Monuments, Sacred Cows, and Measurability

The Statue of Liberty, the Eiffel Tower, the Parthenon, the Great Pyramid of Giza...what do they all have in common?  They are all monuments.  What do monuments have in common?  They stay put.  

Because they are monuments, we expect to find them where they are, as they are, for centuries to come.  Monuments don't move (I'm not counting the London Bridge).  Monuments don't change much either.  And for the most part, we don't want them to move or change.

The London Bridge enjoying retirement in Lake Havasu City, Arizona

But what do we do with a monument when it blocks much-needed progress?

I ask this question not because I think the Taj Majal needs to be moved down the street to make way for a freeway or anything, but because we encounter monuments everyday in the business world.  In this context, the term 'monument' refers to something that is looked at as immobile, unchangeable, or sacrosanct.

In manufacturing, an example of a monument is a big piece of equipment that can't be moved because it physically can't fit anywhere else.  In healthcare, an example might be a department or program that will not change its processes because it has been deemed a "Sacred Cow" that is not to be bothered.

So how do we deal with these monuments when they block much-needed progress?

Dealing with monuments after the fact can be problematic.  Once something comes to be viewed as inviolable, we start to use terms like "act of Congress" to describe what it would take to change it.  Not good.  We need to prevent monuments from being erected in the first place.  

For a physical monument, like a big piece of equipment, prevention can be achieved by simply not purchasing it, or maybe by purchasing smaller, more flexible alternatives.  However, for an intangible monument, like a Sacred Cow department or program, the situation is more nuanced.  In this scenario, prevention can be achieved by incorporating the concept of measurability into our management decisions. 

Just to be clear, I'm not a person who believes the adage that "if you can't measure it, you can't manage it."  Not everything that is important is measurable.  And I prefer facts over data, so I'm not saying we should go hardcore Six Sigma and attach a metric to every activity in the organization just for the sake of having more data.  

I'm just saying that, all things being equal, it's better to be able to measure something than to not, because in the absence of measurability, personal influence and persuasiveness rule the day.  That's how you end up with Sacred Cow monuments that long outlive their usefulness and block progress.

For that reason, I'd go with an option that may not be quite as good but that is measurable over an option that maybe be a little better but immeasurable.  But I'm not sure many management teams would go along with that.  We're just too hardwired to look at the available options and make the best choice based on the evidence on-hand at the moment.  That's why we have a lot of problematic monuments in our organizations.

Move to Healthcare

Been so wonderfully busy at the hospital that I haven't had a chance to post at all in a few months.  I did, however, have one of my old articles written on the "Move to Healthcare" site cross-posted over to Mark Graban's Lean Blog.  The article is nearly two years old now, but I think it is still relevant to those lean thinkers out there looking to get into healthcare.  Here's the link:

Farewell to the “Move to Healthcare” Ning Group; Sharing a Success Story

IT Systems vs. Busines Systems

I was watching a lecture on the subject of information management/information technology/etc., and the lecturer began discussing systems thinking, a favorite subject of mine.  I was expecting a Senge-like discussion, and maybe an explanation of how information technology plays a role in a modern business system.  But the lecturer had a different viewpoint.  I think he saw IT systems and business systems as being synonymous.  In other words, the professor's view seemed to be:

Business System = IT System

This equation implies an IT-centric approach to business with which I disagree.  I see IT systems as only one part of a larger business system.  My equation is more like:

Business System = People + Processes + Management + Technology + Lots of Other Inputs

For me, IT systems are just one type of technology, which is just one type of input into a business system.  Sure, for e-commerce and other Internet-based endeavors, IT systems are extremely prominent features of the business system.  But even then, they're not the only features.  So often in the business world it feels like this is forgotten.

I would recommend to IT professionals and others in charge of developing, managing, or improving business systems that they take a step back and see things holistically.  Don't be overly focused on technology as a silver bullet, even if IT is your area of expertise.  Use IT systems to support the business instead of seeing IT systems as the business.

Top 3 Things I've Learned After 18 Months in Healthcare

It's been almost 18 months since I made the move to healthcare, thanks in part to the encouragement I received from my friend, Mark Graban.  In that time, I've learned a lot and I continue to learn everyday.  What have I learned?  Here's my Top 3 list:

1. The healthcare business is all about people.  In my article "The Human Factor in Healthcare," I discuss how important it is to be agile when it comes to how we approach improvement in healthcare because of the human factor.  This is by far the most important lesson I've learned in healthcare.  Our "product" is the patient, a human being.  Most of our processes are highly dependent upon manual labor, which is performed by human beings.  We have front-line workers (doctors and nurses) with much more education, training, and influence that the average front-line worker in a factory.  In pediatrics, we have to account for the needs of not only the patient, but of the patient's family as well.  In an academic healthcare setting, we have to account for the learning needs of medical students, residents, and fellows.  The human element exists in every industry; it's hugely magnified in healthcare.
2. The healthcare business is complex.  In my article "10 Complexities in Hospitals," I discuss how many different levels of complexity we encounter in healthcare.  The end-user and the payer are often different entities with completely different goals.  We are highly regulated by national agencies, state agencies, the Joint Commission, and other entities with differing goals.  We implement technology solutions of Rube Goldberg proportions that I've come to believe nobody fully understands.  We have a nearly infinite amount of data at our disposal, of which only a fraction is actually timely, relevant, and easy to use.  Healthcare reform is creating huge paradigm shifts (pardon the business cliche) in every healthcare organization in the land.  Changing priorities are the norm, and it makes things really complex.
3. The healthcare business can be wonderful.  Many of the people I've met in healthcare have been passionate, committed, highly-intelligent, experienced, interested in learning, focused on serving the needs of the patient, and highly competent.  Not everybody, but a high percentage.  That makes for a wonderful workplace.  Plus, it's just easier to get up in the morning when you know your work might help make a sick child's life a little better, even if indirectly through process improvement or whatever.

Like I said earlier, I've learned a lot (a lot more than is shown here) and I continue to learn everyday.  If you're an engineer, project manager, quality professional, operations manager, or any other type of business professional, you can make the move to healthcare.  Just be ready to focus on people, deal with complexity, and be proud of your work.  Most of all, be ready to continuously learn and improve.

True Value in Healthcare

In the year and a half that I've been working in healthcare, I've heard some really good arguments from some really smart folks regarding what makes an activity value-added.  Based on what I've heard, read, studied, and observed, the prevailing approach to defining value in healthcare is the following:

The Standard Definition of Value in Healthcare

Under this definition, for an activity to be considered value-added, it must satisfy three requirements:

1. The activity must be something the patient wants/needs
2. The activity must be done correctly
3. The activity must change the form/fit/function of the patient

If it does not satisfy all three of these requirements, an activity is considered non-value-added under this approach.  

This is a pretty strict approach, especially considering that it does not recognize the value of activities that contribute to the correct diagnosis of illness, something which I believe is of tremendous value to the patient.  Until recently, I've tended to favor a slightly more lax definition of value.  

But the more and more I read about Population Health and ACO, the more and more I've begun to question the the standard definition of value in healthcare.  I've started to subscribe to a more systemic and holistic definition of value, which I refer to as True Value.

My Definition of True Value in Healthcare

The following two guidelines define my current, half-baked view of "true" value in healthcare:

1. If an activity is related to providing care for a preventable illness, it is waste.
2. If an activity is related to providing care for an unpreventable illness, and satisfies the three requirements of The Standard Definition of Value in Healthcare as shown above, it is value-added

Thoughts?  

FYI, I prefer comments on LinkedIn or Twitter, so I've shut off comments on this blog.

Thank you for sponsoring my Little League team.  Those mesh hats were sweet.

The Human Factor in Healthcare

Several times recently, I've been asked by manufacturing folks about the challenges of making the move to healthcare as a lean coach.  The one challenge that I always emphasize is the human factor.  The human factor exists in every industry, but it's magnified in healthcare.  This is partly due to the manual nature of the work, partly due to to the fact that the product is the patient, and partly due to the unique cultural aspects of working in an organization that directly saves lives on a daily basis.

As a lean coach in healthcare, one must adjust both his or her expectations and tactics.

Adjust Your Expectations

Expect a lot of variation.  I mean a lot of variation.  Even with a calibrated, properly maintained, properly operated piece of machinery, we expect a level of variation.  Now take away the calibration, maintenance, and proper operation and see how much variation you get.  Now take away the machine altogether, replace it with a person, and see how much variation you get.  I could go on, but I think I've made my point.  Expect a lot of variation!

Adjust Your Tactics

As for our tactics, we must adjust them to take into account the human factors.  We have to design around the needs of not only the patient, but also the family of the patient.  We might have to make choices we don't want to make to accomodate the teaching needs of an academic hospital.  We have to define value in terms of not only the patient, but also of the payer.  There are so many layers of complexity that prevent us from getting to an optimal future state, but we can't let that stop us from moving towards at least a better future state.  We have to adjust our tactics and be much more agile.

Experiments as Nemawashi

Lean folks have heard the term nemawashi.  I've heard it described as preparing the roots of a plant for transport.  It's related to consensus-building, and is especially critical when we are proposing big changes to a process.

I started thinking about nemawashi last week when I was in Six Sigma training.  We were learning about Design of Experiments (DOE), which is a methodical and data-driven approach to testing future-state processes, potential countermeasures, etc.  Immediately, I started to compare and contrast the DOE approach to the less scientific Barn-Raising Kaizen and Quick PDCA approaches that have served me well in the past.  I wondered how we were able to achieve what we did without the rigor that DOE provides.  Then it dawned on me that one of the reasons for our success with these less rigorous and more action-biased approaches was that we were performing a type of nemawashi.

We have all probably seen this formula...

R = Q x A 

...which of course stands for...

  Results = Quality of the Countermeasure x Acceptance Level.

Whenever we test a new countermeasure, we are doing more than collecting data to check the quality of the countermeasure.  We are also impacting the acceptance level for change.  If done right, an experiment can help remove the fear of the unknown, send a message that change is coming, and bring out ideas that don't arise until we see a new process live in action.  These are all symptoms of nemawashi being performed.