PDSA over PDCA

Karen Martin wrote an excellent post a while back on Mark Graban's Lean Blog, so there's really no need to write this post, but I'm going to do it anyway because it's fun in a really nerdy kind of way.

Study, not Check

Anyway, like Karen and Dr. Deming, I also agree that the third step of the Shewhart Cycle for Learning and Improvement should be 'Study' as opposed to 'Check.'  Let's play word association with these two words:

• When I think of 'Study' I think:  learning, impartial, scientist, curious, absorbing, methodical
• When I think of 'Check' I think:  just verifying, yep I got what I expected, let's move on quickly

Doing a check is better than the approach most people use, which consists of implementing blindly toward an end point that never seems to arrive or which disappoints when it finally does.  But, 'Check' does not encourage a scientific mentality our curious learner attitude the way 'Study' does.  Improvement activities in their finest form are examples of the scientific method being applied to everyday opportunities for improvement, and we so often fail to understand that.  Hence, the quick check on the way to finishing a PDCA cycle and no value given to the learning part of the Shewhart Cycle.

Act, not Adjust (maybe)

Where I might (not definitely but maybe) diverge from Karen's view is with my preference of 'Act' over 'Adjust' as the fourth step of the Shewhart Cycle.  After studying the results of an experiment, there are actions to be performed regardless of whether adjustments are needed or not.  In practice, this is a moot point because adjustments are always needed, but I like to send the message through the use of the word 'Act' that action is required regardless of the outcome we achieved.  Other than adjustment, what actions might be required?  Here's a short list:

• Sharing:  regardless of what we learned or what outcome we achieved, we should share our learning broadly across the organization i.e. yokoten.
• Standardizing:  even if a change is not perfect (and will require adjustment), we might benefit from implementing the change into our work through the use of standard work, job instruction training, etc.

Semantics Matter

Again, I can see why 'Adjust' might be better and I'm not averse to it the way I am with 'Check.'  And yes, in the end it's just semantics, but when we're trying to establish a True North for how we go about learning and improving (which I hope all the lean coaches out there are doing on a daily basis), semantics matter.  A lot!

Top 3 PDSA Mistakes

Everybody Most people involved with process improvement have heard of the Plan-Do-Study-Act cycle. Many think of it as a tool or technique, but I see it as a habit. In fact, I see it as a keystone habit that, if hardwired in an organization, can set the stage for many other lean habits to emerge.

Unfortunately, however, PDSA can be deceptively tricky to execute properly. On the surface, it looks simple; "it's just a 4-step routine." But one needs a scientific mentality to perform PDSA properly, and most folks are not trained to think about process problems scientifically.

Based on my experience from the front-lines of process improvement in healthcare, here are the top 3 most common PDSA mistakes I see:

3) Not stating a hypothesis in the Plan phase. Maybe the word 'hypothesis' throws people off, or maybe people don't want to admit that they are just making a prediction i.e. aren't sure that their idea will work, but it's extremely common to see people completely omit any sort of prediction or theory from the Plan phase of their PDSA. When I coach people on PDSA, I usually avoid the word 'hypothesis' and ask them to write a "If we do X, then we predict Y" statement instead.

2) Not being impartial about results in the Study phase. If results are better than expected, we are jubilant instead of curious. If results are worse than expected, we get discouraged and sweep it all under the rug, or we cherry-pick any and every positive indicator we can plausibly use. These behaviors are symptomatic of a non-scientific approach at best, and a punitive organizational culture at worst. When I'm coaching, I emphasize that any good PDSA cycle has value in the form of the learning it generates, independent of whatever the results were for that cycle.

1) Not properly understanding the problem prior to PDSA. PDSA is a great approach for testing ideas for improvement, but not every idea should be tested. We need a set-up phase prior to PDSA that helps us define the problem on the surface, dig down to root causes, and use the insights we gain to develop good ideas for improvement that can be tested. So often, we get so excited to implement change that we hurry past this set-up phase, which increases the risk of selecting the wrong idea to test. This is okay, in that PDSA will reveal that it's the wrong idea, but we only have so much capacity for testing, so we need to be smart about what ideas we select. When coaching, I try to challenge our understanding of the problem, but in the end, I usually show a bias for action.

Value = Quality/Cost

Over Christmas break down in the Yucatan Peninsula, I read Dr. Toussaint's book "Potent Medicine." He reminded me of the old equation for value: Value = Quality/Cost. Increase quality and reduce cost and you increase value to the customer. Great concept.

My company, a large healthcare system, defines the 'Quality' part of the equation as Outcomes x Safety x Service. I think that's a great way to look at quality in healthcare.

Taken together, the two equations are: Value = (Outcomes x Safety x Service)/Cost. If you, like me, are in a position of leadership responsible for engraining a lean mindset in a healthcare organization, keep in mind that you will want to connect the dots between each of these components of value. If you don't, there's a distinct possibility that nobody will.

Also, you will want to focus on building the habits needed for increasing value via quality improvement and cost reduction. One keystone habit is the use of PDSA to test ideas when an opportunity for improvement is identified. If you can hardwire that habit, it will set the stage for other positive habits to flourish. Habits such as: going to the gemba to find OFIs, using 5-Why? to get at root causes of problems, and engaging teams of people in problem-solving. To help hardwire PDSA as a habit, another habit, the coaching of PDSA, is critical. Or, to simplify the whole thing a bit, just start talking about, teaching, modeling, and using PDSA all the time for everything.

Improve value. Connect the dots. Hardwire PDSA as a habit. Be a great lean leader.

Habit-Building

I'm really liking The Power of Habit:  Why We Do What We Do in Life and Business by Charles Duhigg.  Taken along with the Mike Rother's Toyota Kata, you have the basics of what it takes to create a continuous improvement culture.

For clarity's sake, I define a continuous improvement culture as an environment in which we strive to improve every process, every day, with everybody involved.  No improvement is too small, we don't batch all our improvements into big projects, and anybody in the organization can be an improvement leader.  For more information on this concept applied to healthcare, see Graban & Swartz' book Healthcare Kaizen.

Anyway, in Duhigg's book, the habit-building loop is presented.  It has three components:

1. Trigger:  this is the cue to perform a routine
2. Routine:  this is the standard steps performed to arrive at the desired result
3. Reward:  this is the payoff for performing the routine on-cue

When these three elements are in-place and clearly related, a craving eventually forms.  This craving causes the habituated person to anticipate the reward at the trigger point, even before performing the routine.  This phenomenon is the indicator of a well-formed habit (for better or for worse!).

While Duhigg's book is about the science behind habit-forming, Rother's book is about the habits needed to drive continuous improvement.  Specifically, he emphasizes two habits (he uses the term 'kata'):

• Improvement Kata:  this is a 4-step routine that helps us 1) see the ideal condition to which we strive, 2) study the current condition to see our gaps, 3) set a short-term target condition to pursue that is on the path to the ideal condition, and 4) pursue the target condition using PDSA (another 4-step routine).
• Coaching Kata:  this is a routine, drawing upon the Socratic Method of teaching (asking questions instead of giving answers), that is designed to reinforce the proper execution of the aforementioned Improvement Kata.

So, how do we put in place the three elements of the habit-building loop for the two kata?  How do we create a craving for the kata?  The routines (element #2 of the habit-building loop) are established by Rother's book.  The other two elements, triggers and rewards, are TBD for me personally.  Some thoughts:

• Triggers:  eventually, the ideal would be that the trigger is the detection of a problem/gap/opportunity for improvement, but in the short-term, more artificial triggers may be needed (i.e. require each manager to perform one PDSA cycle per month...not a long-term solution, but can get the ball rolling in the short-term).
• Rewards:  eventually, the ideal would be that the reward would be the intrinsic motivators of mastery, autonomy, and purpose (see Daniel Pink's Drive), but in the short-term, more artificial rewards may be needed (i.e. gamification:  badges, achievements, recognition, compliance tracking, small gifts, etc.)

This type of habit-building is tricky business.  Culture change is hard.  It takes a wide range of knowledge, organizational finesse, and a lot of trust and patience on the part of senior leadership.  But the payoff is huge.  A culture of continuous improvement is the best, most sustainable competitive advantage available.

Freudian Gaps (The Softer Side of Lean)

The fundamental talent of a lean coach is to get a team to see the difference between the ideal state and the current state, but in a way that does not alienate team members or cause inadequate solution selection.  In other words, in pointing out the gap, we can't just come out and say what the gap is.  People in our culture equate identifying a gap with assigning blame for a gap; we're not great at separating problems from personalities.  So, don't be blaming, i.e. don't be pointing out gaps.

Instead, help the team gradually come to gap realization in a methodical way that decouples gap existence from gap culpability by means of an almost subconscious circumvention of the blame-game gag reflex.  Before the team members even realize who is "guilty," they will have been introduced to the gap in an impartial manner.  This impartiality helps drive more nuanced understanding of the problem, and thus, better interventions that more directly address root causes.  So in other words, ask questions; be a coach.

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